Provider Demographics
NPI:1851416432
Name:JERRAD SCOTT MILLS
Entity Type:Organization
Organization Name:JERRAD SCOTT MILLS
Other - Org Name:DEER PARK VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-479-4570
Mailing Address - Street 1:2009 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-4161
Mailing Address - Country:US
Mailing Address - Phone:281-479-4570
Mailing Address - Fax:
Practice Address - Street 1:2009 CENTER ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-4161
Practice Address - Country:US
Practice Address - Phone:281-479-4570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02082152W00000X
TX6368TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0042PPOtherBLUE CROSS BLUE SHIELD
TX1104829464OtherNPI
TX00X988Medicare PIN
TX0042PPOtherBLUE CROSS BLUE SHIELD