Provider Demographics
NPI:1689801417
Name:MACMILLAN, CARLENE M (MD)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:M
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 NORTHSIDE PIERS
Mailing Address - Street 2:PH6
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249
Mailing Address - Country:US
Mailing Address - Phone:929-227-6577
Mailing Address - Fax:
Practice Address - Street 1:58 N 9TH ST STE 103
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-2018
Practice Address - Country:US
Practice Address - Phone:929-227-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2785172084P0800X, 2084P0804X
MA2489582084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110094989AMedicaid
MA003223501Medicare Oscar/Certification