Provider Demographics
NPI:1073537817
Name:MILLER, KENNETH JOEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-547-9991
Mailing Address - Fax:310-547-2389
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 215
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-547-9991
Practice Address - Fax:310-547-2389
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC30205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042930Medicaid
CAW1629Medicare PIN
CAGR0042930Medicaid