Provider Demographics
NPI:1821095795
Name:MILLS, MICKEY O (MD)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:O
Last Name:MILLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6400 MARLBORO PIKE
Mailing Address - Street 2:UPPER LEVEL
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747
Mailing Address - Country:US
Mailing Address - Phone:301-736-7000
Mailing Address - Fax:301-736-6916
Practice Address - Street 1:6400 MARLBORO PIKE
Practice Address - Street 2:UPPER LEVEL
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747
Practice Address - Country:US
Practice Address - Phone:301-736-7000
Practice Address - Fax:301-736-6916
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G68278Medicare UPIN
015867H08Medicare ID - Type Unspecified