Provider Demographics
NPI:1962627802
Name:MILLAR, MARK MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MARSHALL
Last Name:MILLAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 E PARIS AVE SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8371
Mailing Address - Country:US
Mailing Address - Phone:616-957-1912
Mailing Address - Fax:616-957-0074
Practice Address - Street 1:1179 E PARIS AVE SE
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8371
Practice Address - Country:US
Practice Address - Phone:616-957-1912
Practice Address - Fax:616-957-0074
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071401207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI347887810Medicaid
MIN99890001Medicare ID - Type Unspecified
MI347887810Medicaid