Provider Demographics
NPI:1245613082
Name:MILLETTE, THEODORE J II (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:MILLETTE
Suffix:II
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3719208000000X
VA0101272247208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics