Provider Demographics
NPI:1003449539
Name:MILLER, CLIFTON WAYNE
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3162
Mailing Address - Country:US
Mailing Address - Phone:910-783-9062
Mailing Address - Fax:
Practice Address - Street 1:1645 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3162
Practice Address - Country:US
Practice Address - Phone:910-783-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY858976812OtherNY STATE ID