Healthcare Provider Details

I. General information

NPI: 1629773940
Provider Name (Legal Business Name): BRANDON MILLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PENNSYLVANIA AVE
FORT WORTH TX
76104-2122
US

IV. Provider business mailing address

3201 SPRINGHILL DR STE 100
NORTH LITTLE ROCK AR
72117-2905
US

V. Phone/Fax

Practice location:
  • Phone: 405-512-7721
  • Fax:
Mailing address:
  • Phone: 501-955-4530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberV2792
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberV2792
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: