Provider Demographics
NPI:1336255793
Name:THALER, MILLARD PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:MILLARD
Middle Name:PHILLIP
Last Name:THALER
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 1:2150 S DOBSON ROAD
Mailing Address - Street 2:STE #1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202
Mailing Address - Country:US
Mailing Address - Phone:480-820-9774
Mailing Address - Fax:480-897-0820
Practice Address - Street 1:2150 S DOBSON ROAD
Practice Address - Street 2:STE #1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-820-2974
Practice Address - Fax:480-897-0820
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-34444207N00000X
AZ13111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0032750OtherBCBS
D00441Medicare UPIN
AZ0032750OtherBCBS