MEDICARE: WALTER MCMILLAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207U00000X	Nuclear Medicine Physician	RHN00003576	CA

General Provider Information

NPI Number	:	1255950655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER MCMILLAN

Provider Business Mailing Address
First Line	:	3740 SANTA ROSALIA DR APT 308
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-3624
Country	:	US
Telephone Number	:	323-385-6469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3740 SANTA ROSALIA DR APT 308
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-3624
Country	:	US
Telephone Number	:	323-385-6469
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	04/15/2020

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