MEDICARE: DR. LACEY MCMILLAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0127X	Trauma Surgery Physician	1017531	MA
2	2086S0127X	Trauma Surgery Physician	DR.0068531	CO
3	2086S0127X	Trauma Surgery Physician	2026-00086	NC
4	2086S0127X	Trauma Surgery Physician	0101286193	VA
5	2086S0127X	Trauma Surgery Physician	2024044388	MO
6	2086S0127X	Trauma Surgery Physician	T3133	TX
7	208600000X	Surgery Physician	TRN23830	FL
8	2086S0127X	Trauma Surgery Physician	ME148659	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U9993	OTHER	FL	MEDICARE HF
2	U9996	OTHER	FL	MEDICARE HFPS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760832117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LACEY MCMILLAN MD

Provider Business Mailing Address
First Line	:	27617 TIERRA DEL SOL LN
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-3553
Country	:	US
Telephone Number	:	305-619-1680
Fax Number	:

Provider Business Practice Location Address
First Line	:	630 S FLEISHEL AVE
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2041
Country	:	US
Telephone Number	:	903-606-5560
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2016
Last Update Date	:	03/18/2026

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