Provider Demographics
NPI:1255950655
Name:MCMILLAN, WALTER
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 SANTA ROSALIA DR APT 308
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3624
Mailing Address - Country:US
Mailing Address - Phone:323-385-6469
Mailing Address - Fax:
Practice Address - Street 1:3740 SANTA ROSALIA DR APT 308
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3624
Practice Address - Country:US
Practice Address - Phone:323-385-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHN00003576207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty