Provider Demographics
NPI:1366738759
Name:MCMILLEN, THOMAS RICHARD (C PED)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RICHARD
Last Name:MCMILLEN
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112-16 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:347-609-2980
Mailing Address - Fax:718-849-3166
Practice Address - Street 1:112-16 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:347-609-2980
Practice Address - Fax:718-849-3166
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPED3518335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier