Basic Information
Provider Information | |||||||||
NPI: | 1023561107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLS | ||||||||
FirstName: | ISAAC | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLS | ||||||||
OtherFirstName: | ISAAC | ||||||||
OtherMiddleName: | PATTON | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | USA MEDDAC | ||||||||
Address2: | 11050 MT BELVEDERE BLVD | ||||||||
City: | FORT DRUM | ||||||||
State: | NY | ||||||||
PostalCode: | 13602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157722778 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11050 MOUNT BELVEDERE BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT DRUM | ||||||||
State: | NY | ||||||||
PostalCode: | 13602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157722778 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2016 | ||||||||
LastUpdateDate: | 10/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3232 | WV | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.