Healthcare Provider Details

I. General information

NPI: 1205254190
Provider Name (Legal Business Name): JAKE C. MCMILLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10841 HARDIN VALLEY RD
KNOXVILLE TN
37932-1410
US

IV. Provider business mailing address

1124 E WEISGARBER RD STE 104
KNOXVILLE TN
37909-2686
US

V. Phone/Fax

Practice location:
  • Phone: 865-584-0905
  • Fax: 865-584-3892
Mailing address:
  • Phone: 865-584-2127
  • Fax: 865-392-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number58987
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberR6836
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number58987
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: