Provider Demographics
NPI:1083603831
Name:MILLER, DANISE JOANN (OD)
Entity Type:Individual
Prefix:MISS
First Name:DANISE
Middle Name:JOANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5782 GORRON RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2498
Mailing Address - Country:US
Mailing Address - Phone:320-630-1214
Mailing Address - Fax:320-632-2558
Practice Address - Street 1:222 4TH ST NE
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-2428
Practice Address - Country:US
Practice Address - Phone:218-894-1331
Practice Address - Fax:218-894-1335
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNMN2873152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN132744500Medicaid
MN410002164Medicare PIN
MN132744500Medicaid