Provider Demographics
NPI:1053638064
Name:MILLER, MOLLIE T
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:T
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 1057
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1057
Mailing Address - Country:US
Mailing Address - Phone:303-486-5500
Mailing Address - Fax:303-486-5502
Practice Address - Street 1:1339 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2301
Practice Address - Country:US
Practice Address - Phone:719-285-2700
Practice Address - Fax:719-285-2455
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48291207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48291OtherSTATE LICENSE