Healthcare Provider Details

I. General information

NPI: 1285078014
Provider Name (Legal Business Name): MARK PHILIP MACMILLAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTHAMPTON STA
RICHMOND VA
23226-3330
US

IV. Provider business mailing address

400 WESTHAMPTON STA
RICHMOND VA
23226-3330
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-4200
  • Fax: 804-287-4210
Mailing address:
  • Phone: 804-287-4200
  • Fax: 804-287-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618002308
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: