Provider Demographics
NPI:1033172531
Name:MILLER, DEWAYNE
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
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 1:102 HIPPOCRATES WAY
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3484
Mailing Address - Country:US
Mailing Address - Phone:270-629-5678
Mailing Address - Fax:
Practice Address - Street 1:102 HIPPOCRATES WAY
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3484
Practice Address - Country:US
Practice Address - Phone:270-629-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0946702Medicare ID - Type Unspecified