Provider Demographics
NPI:1114451259
Name:MILLER, CORY JAY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:JAY
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 20TH ST NW STE 101
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2931
Mailing Address - Country:US
Mailing Address - Phone:507-209-6214
Mailing Address - Fax:507-209-6220
Practice Address - Street 1:1575 20TH ST NW STE 101
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2931
Practice Address - Country:US
Practice Address - Phone:507-332-9900
Practice Address - Fax:507-209-6220
Is Sole Proprietor?:No
Enumeration Date:2017-04-15
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN69264207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program