Provider Demographics
NPI:1124011978
Name:MILLER, CHARLES E (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4519
Mailing Address - Country:US
Mailing Address - Phone:715-387-6397
Mailing Address - Fax:715-384-6140
Practice Address - Street 1:605 E 4TH ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4519
Practice Address - Country:US
Practice Address - Phone:715-387-6397
Practice Address - Fax:715-384-6140
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3917827250OtherBLUE CROSS BLUE SHIELD
WI511029OtherNVA
WI73400OtherVIPA
WI33994OtherSECURITY HEALTH
WI38705100OtherHIRSP
WI38705100Medicaid
WI410026847OtherRAILROAD MEDICARE
WI87726OtherADVOCARE
WI27707OtherSPECTERA
WI5712-001OtherEYEMED
WI33994OtherSECURITY HEALTH
WI410026847OtherRAILROAD MEDICARE
WI38705100OtherHIRSP