Provider Demographics
NPI:1932119088
Name:MILLARD, JONATHAN KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEVIN
Last Name:MILLARD
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:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-9769
Practice Address - Country:US
Practice Address - Phone:803-581-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85495207P00000X
NC011233708207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135FUMedicaid
SCN00840Medicaid
NCH94276Medicare UPIN
NC2022864BMedicare ID - Type Unspecified