Provider Demographics
NPI:1588748891
Name:MCMILLIAN, LOTHAR (MD)
Entity type:Individual
Prefix:
First Name:LOTHAR
Middle Name:
Last Name:MCMILLIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:655 CAMINO DE LOS MARES
Mailing Address - Street 2:STE 124
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2809
Mailing Address - Country:US
Mailing Address - Phone:949-661-9767
Mailing Address - Fax:949-661-1352
Practice Address - Street 1:7777 MILLIKEN AVE # B
Practice Address - Street 2:STE 240
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6780
Practice Address - Country:US
Practice Address - Phone:909-941-0247
Practice Address - Fax:909-948-7950
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA45238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0971357OtherTAX IDENTIFICATION NUMBER
CA00A452380Medicare PIN
CA33-0971357OtherTAX IDENTIFICATION NUMBER