Provider Demographics
NPI:1386696664
Name:MILLETT, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MILLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 3 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8251
Mailing Address - Country:US
Mailing Address - Phone:616-785-3883
Mailing Address - Fax:
Practice Address - Street 1:1550 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-8251
Practice Address - Country:US
Practice Address - Phone:616-785-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598712390OtherGROUP NPI
MI1649287517OtherGROUP NPI
MI0M80080OtherMEDICARE
MI4779268Medicaid
MI4779286Medicaid
MI4779301Medicaid
MI4779277Medicaid
MI0804114922OtherBCBS
MI4779295Medicaid