Provider Demographics
NPI:1427230168
Name:FRED L MCMILLAN, MD, PLLC
Entity type:Organization
Organization Name:FRED L MCMILLAN, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-948-6886
Mailing Address - Street 1:1421 N STATE ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-948-6886
Mailing Address - Fax:601-948-7044
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 503
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-948-6886
Practice Address - Fax:601-948-7044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05468207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015679Medicaid
MSB90074Medicare UPIN
MS180000137Medicare PIN