Provider Demographics
NPI:1326002254
Name:MILLARD, ROBERTA L (MD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:MILLARD
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:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:1850 E PARK AVE
Practice Address - Street 2:STE 112
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6706
Practice Address - Country:US
Practice Address - Phone:800-243-1455
Practice Address - Fax:814-863-7803
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043808E207R00000X, 2081S0010X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E71356Medicare UPIN
430173Medicare ID - Type Unspecified