Provider Demographics
NPI:1851461990
Name:MCMILLAN, MISCHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:MISCHELLE
Middle Name:
Last Name:MCMILLAN
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 1:24988 SE STARK ST.
Mailing Address - Street 2:#220
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-674-1580
Mailing Address - Fax:503-674-1581
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:#220
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-674-1580
Practice Address - Fax:503-674-1581
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR081682Medicaid
R103401Medicare ID - Type Unspecified
OR081682Medicaid