Provider Demographics
NPI:1104972710
Name:MILLS, MICHELLE R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:R
Last Name:MILLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:815 SW BOND ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3593
Practice Address - Country:US
Practice Address - Phone:541-382-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46554208000000X
COTL-1770390200000X
ORMD29395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500608725Medicaid
OR500608725Medicaid