Healthcare Provider Details

I. General information

NPI: 1104813567
Provider Name (Legal Business Name): SHANE B. MILLS, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15930 S GREAT OAKS DR A-200
ROUND ROCK TX
78681-5526
US

IV. Provider business mailing address

15930 S GREAT OAKS DR A-200
ROUND ROCK TX
78681-5526
US

V. Phone/Fax

Practice location:
  • Phone: 512-246-3338
  • Fax: 512-346-3368
Mailing address:
  • Phone: 512-246-3338
  • Fax: 512-346-3368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH8260
License Number StateTX

VIII. Authorized Official

Name: SHANE B MILLS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 512-246-3338