Provider Demographics
NPI:1689795304
Name:MILLS, BRANNON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANNON
Middle Name:
Last Name:MILLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10751 EDGEWOOD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577
Mailing Address - Country:US
Mailing Address - Phone:907-622-2225
Mailing Address - Fax:
Practice Address - Street 1:1000 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4218
Practice Address - Country:US
Practice Address - Phone:907-279-8651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK243152W00000X
OR3144ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist