Provider Demographics
NPI: | 1669465589 |
---|---|
Name: | MILLMAN, JONATHAN B (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JONATHAN |
Middle Name: | B |
Last Name: | MILLMAN |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 5700 SOUTHWYCK BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | TOLEDO |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43614-1509 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-288-8325 |
Mailing Address - Fax: | 419-866-5453 |
Practice Address - Street 1: | 6701 AIRPORT BLVD |
Practice Address - Street 2: | SUITE B 218 |
Practice Address - City: | MOBILE |
Practice Address - State: | AL |
Practice Address - Zip Code: | 36608-6776 |
Practice Address - Country: | US |
Practice Address - Phone: | 251-633-3617 |
Practice Address - Fax: | 251-633-9330 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-25 |
Last Update Date: | 2014-10-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AL | 7939 | 207ZP0102X |
MS | 18506 | 207ZP0102X |
AL | MD.7939 | 207ZP0102X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AL | 000039400 | Medicaid | |
MS | 00018252 | Medicaid | |
AL | 39400 | Medicare ID - Type Unspecified | |
AL | 000039400 | Medicaid |