Basic Information
| Provider Information | |||||||||
| NPI: | 1912923905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | MILLICENT | ||||||||
| MiddleName: | BOOKER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOOKER | ||||||||
| OtherFirstName: | MILLICENT | ||||||||
| OtherMiddleName: | CANDENE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DR STE 850 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367022007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2933 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271034001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367943380 | ||||||||
| FaxNumber: | 3367943378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200401028 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 89138AX | 05 | NC | MEDICAID |