Healthcare Provider Details

I. General information

NPI: 1255569968
Provider Name (Legal Business Name): JUSTIN DAVID MILLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

IV. Provider business mailing address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

V. Phone/Fax

Practice location:
  • Phone: 253-845-9585
  • Fax: 253-848-1126
Mailing address:
  • Phone: 253-845-9585
  • Fax: 253-848-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD61265817
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA135513
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD61265817
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: