Provider Demographics
NPI:1104860246
Name:MILLER, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
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 1:630 ADDISON AVE W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5491
Mailing Address - Country:US
Mailing Address - Phone:208-733-4343
Mailing Address - Fax:208-734-9941
Practice Address - Street 1:630 ADDISON AVE W
Practice Address - Street 2:SUITE 100
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5491
Practice Address - Country:US
Practice Address - Phone:208-733-4343
Practice Address - Fax:208-734-9941
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5473208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1105546Medicare ID - Type UnspecifiedMEDICARE NUMBER
IDE69407Medicare UPIN