Provider Demographics
NPI:1205997582
Name:MILLS, MIRIAM V (MD)
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:V
Last Name:MILLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1958
Mailing Address - Country:US
Mailing Address - Phone:918-745-0501
Mailing Address - Fax:918-747-9778
Practice Address - Street 1:3401 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1958
Practice Address - Country:US
Practice Address - Phone:918-745-0501
Practice Address - Fax:918-747-9778
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12177208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100148880AMedicaid