Provider Demographics
NPI:1740298967
Name:MILLETTE, TERRENCE JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:JOHN
Last Name:MILLETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TERRY
Other - Middle Name:J
Other - Last Name:MILLETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-1030
Mailing Address - Country:US
Mailing Address - Phone:228-990-9926
Mailing Address - Fax:
Practice Address - Street 1:3616 HOSPITAL ST
Practice Address - Street 2:SUITE A
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4117
Practice Address - Country:US
Practice Address - Phone:228-990-9926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS09641174400000X, 2084N0400X
IN01077142A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0016486Medicaid
MSC48292Medicare UPIN