Healthcare Provider Details

I. General information

NPI: 1255712618
Provider Name (Legal Business Name): MARIE MCMILLEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SAINT FRANCIS DR STE 201
WATERLOO IA
50702-5664
US

IV. Provider business mailing address

2710 SAINT FRANCIS DR STE 201
WATERLOO IA
50702-5664
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-5000
  • Fax: 319-272-6730
Mailing address:
  • Phone: 319-272-5000
  • Fax: 319-272-6730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number02005698B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberR2489
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDO-05614
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: