Provider Demographics
NPI:1316132582
Name:MCMILLION, CHARYSE M (DO)
Entity type:Individual
Prefix:
First Name:CHARYSE
Middle Name:M
Last Name:MCMILLION
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 STATE RD
Mailing Address - Street 2:VINEYARD SQUARE PLAZA, #9
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-9141
Mailing Address - Country:US
Mailing Address - Phone:440-967-1128
Mailing Address - Fax:440-967-1172
Practice Address - Street 1:1605 STATE RD
Practice Address - Street 2:VINEYARD SQUARE PLAZA, #9
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-9141
Practice Address - Country:US
Practice Address - Phone:440-967-1128
Practice Address - Fax:440-967-1172
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236248Medicaid
OH3067354Medicaid
OH4297331Medicare PIN
OH9284951Medicare PIN