Provider Demographics
NPI:1396786463
Name:MILLICAN, ROBERT J (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MILLICAN
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 1:2311 WOODBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-2955
Mailing Address - Country:US
Mailing Address - Phone:715-341-8053
Mailing Address - Fax:
Practice Address - Street 1:2311 WOODBRIDGE CT
Practice Address - Street 2:SUITE 303
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467
Practice Address - Country:US
Practice Address - Phone:715-341-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28173207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31724700Medicaid
WIE17405Medicare UPIN
WI31724700Medicaid