Provider Demographics
NPI:1770516825
Name:MCMILLAN, WILLIAM BLACK (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BLACK
Last Name:MCMILLAN
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 1:901 N. PORTER AVE.
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 N PORTER AVE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6404
Practice Address - Country:US
Practice Address - Phone:412-308-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035193L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD035193LOtherPA STATE MEDICAL LICENSE
PAD71343Medicare UPIN
PAMC 158741 JTHMedicare ID - Type UnspecifiedMEDICARE PROVIDER #