Provider Demographics
NPI:1760832117
Name:MCMILLAN, LACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16913 NW 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-7029
Mailing Address - Country:US
Mailing Address - Phone:056-191-6803
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-443-7057
Practice Address - Fax:508-856-4224
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN 23830208600000X
FLME1486592086S0127X
MA10175312086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPI831OtherHFPSI MA
FLPI832OtherHFIC MA