Provider Demographics
NPI:1972596807
Name:MILLEVILLE, MARK WILLIAM (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:MILLEVILLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3702 MEADOWBROOK ACRES
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120
Mailing Address - Country:US
Mailing Address - Phone:716-692-4255
Mailing Address - Fax:
Practice Address - Street 1:3571 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120
Practice Address - Country:US
Practice Address - Phone:716-695-7848
Practice Address - Fax:716-695-0312
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0112481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11515444OtherCAQH
NY11515444OtherCAQH