Provider Demographics
NPI:1104832294
Name:MILLER, DANIEL JASON
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JASON
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:JASON
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:258 GEREMMA DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3334
Mailing Address - Country:US
Mailing Address - Phone:314-283-8421
Mailing Address - Fax:
Practice Address - Street 1:3136 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5013
Practice Address - Country:US
Practice Address - Phone:618-452-2300
Practice Address - Fax:618-452-0373
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06026803OtherBLUE CROSS & BLUE SHIELD
593100Medicare ID - Type Unspecified
IL06026803OtherBLUE CROSS & BLUE SHIELD