Provider Demographics
NPI:1003095761
Name:MILLER, MARK L (RCS,RVS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:RCS,RVS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 12B
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-529-2498
Mailing Address - Fax:208-528-7971
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 12B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-529-2498
Practice Address - Fax:208-528-7971
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular