Healthcare Provider Details

I. General information

NPI: 1962627802
Provider Name (Legal Business Name): MARK MARSHALL MILLAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE SUITE 150
GRAND RAPIDS MI
49546-8371
US

IV. Provider business mailing address

1179 E PARIS AVE SE SUITE 150
GRAND RAPIDS MI
49546-8371
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-1912
  • Fax: 616-957-0074
Mailing address:
  • Phone: 616-957-1912
  • Fax: 616-957-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301071401
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: