Provider Demographics
NPI:1841440690
Name:MILLSAP, MICHAEL E (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:MILLSAP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27 MONTEBELLO RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1236
Mailing Address - Country:US
Mailing Address - Phone:719-545-1530
Mailing Address - Fax:719-545-2899
Practice Address - Street 1:515 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2805
Practice Address - Country:US
Practice Address - Phone:719-539-3581
Practice Address - Fax:719-539-4992
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08013658Medicaid
COCOA104412OtherMEDICARE