Healthcare Provider Details

I. General information

NPI: 1053568469
Provider Name (Legal Business Name): DOUGLAS R MCMILLIN BD-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3843 MOLLER RD
INDIANAPOLIS IN
46254-2930
US

IV. Provider business mailing address

3843 MOLLER RD
INDIANAPOLIS IN
46254-2930
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-3376
  • Fax: 317-291-3746
Mailing address:
  • Phone: 317-291-3376
  • Fax: 317-291-3746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17000937
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1199
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: