Healthcare Provider Details

I. General information

NPI: 1174591036
Provider Name (Legal Business Name): THEODORE MICHAEL MILLETTE M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 HOSPITAL ST STE 103
PASCAGOULA MS
39581-5312
US

IV. Provider business mailing address

4105 HOSPITAL ST STE 103
PASCAGOULA MS
39581-5312
US

V. Phone/Fax

Practice location:
  • Phone: 228-762-8712
  • Fax: 228-762-2261
Mailing address:
  • Phone: 228-762-8712
  • Fax: 228-762-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number09156
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: