Provider Demographics
NPI:1972566990
Name:MILLIS, ADAM S (OD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:S
Last Name:MILLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 GLENSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-1220
Mailing Address - Country:US
Mailing Address - Phone:215-887-1441
Mailing Address - Fax:
Practice Address - Street 1:352 GRIBBEL RD
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-1108
Practice Address - Country:US
Practice Address - Phone:215-206-8526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-001677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAV05894Medicare UPIN