Provider Demographics
NPI:1033253745
Name:MILLER, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:13270 S CEDAR CIR
Mailing Address - Street 2:
Mailing Address - City:PINE
Mailing Address - State:CO
Mailing Address - Zip Code:80470-9408
Mailing Address - Country:US
Mailing Address - Phone:303-838-5443
Mailing Address - Fax:
Practice Address - Street 1:2045 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5437
Practice Address - Country:US
Practice Address - Phone:303-861-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO93776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
006713OtherKAISER-COMMERCIAL NUMBER