Provider Demographics
NPI:1073575353
Name:MILLER, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 W LA PALMA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2815
Mailing Address - Country:US
Mailing Address - Phone:714-635-9680
Mailing Address - Fax:714-635-2924
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2815
Practice Address - Country:US
Practice Address - Phone:714-635-9680
Practice Address - Fax:714-635-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28208207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ098672OtherBLUE SHIELD OF CALIF
CA00G282080Medicaid
CA00G282080Medicaid
CAZZZ098672OtherBLUE SHIELD OF CALIF