Provider Demographics
NPI:1053384164
Name:MCMILLAN, DAMON C (MD)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:C
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5506
Mailing Address - Country:US
Mailing Address - Phone:850-576-4073
Mailing Address - Fax:850-576-2824
Practice Address - Street 1:1720 S GADSDEN ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5506
Practice Address - Country:US
Practice Address - Phone:850-576-4073
Practice Address - Fax:850-576-2824
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5399OtherBC/BS OF FLORIDA
FL209999OtherHEALTHEASE FLORIDA #2
FL255569700Medicaid
FLSG075553OtherVISTA (MEDICAID)
FL162001OtherHEALTHEASE OF FLORIDA#1
FL162001OtherHEALTHEASE OF FLORIDA#1
FLSG075553OtherVISTA (MEDICAID)