Provider Demographics
NPI:1548468580
Name:MILLS, MICAH SEAN (OD)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:SEAN
Last Name:MILLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 S KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4826
Mailing Address - Country:US
Mailing Address - Phone:208-459-2641
Mailing Address - Fax:208-459-2895
Practice Address - Street 1:1702 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4826
Practice Address - Country:US
Practice Address - Phone:208-459-2641
Practice Address - Fax:208-459-2895
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100163152W00000X
OR3254AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1548468580Medicaid
ID1548468580Medicaid
ID0396900001Medicare NSC