Provider Demographics
NPI:1952627069
Name:MILLS, JON RANDALL JR (DO)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:RANDALL
Last Name:MILLS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1195
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008
Mailing Address - Country:US
Mailing Address - Phone:580-278-6804
Mailing Address - Fax:888-498-4576
Practice Address - Street 1:3815 W. CARRIER RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703
Practice Address - Country:US
Practice Address - Phone:580-278-6804
Practice Address - Fax:888-498-4576
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200400290AMedicaid
OKOKAAA3348Medicare PIN