Provider Demographics
NPI:1003819566
Name:MILLER, JOHN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-0483
Mailing Address - Country:US
Mailing Address - Phone:530-758-1580
Mailing Address - Fax:530-758-9869
Practice Address - Street 1:2055 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-0672
Practice Address - Country:US
Practice Address - Phone:530-758-1580
Practice Address - Fax:530-758-9869
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14926103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA140207Medicare UPIN
CA253181OtherMANAGED HEALTH NETWORK
CAZZZ07402ZMedicare PIN