Provider Demographics
NPI:1124028220
Name:MILLER, FRED DOUGLAS (MD)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:DOUGLAS
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 1:15216 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3734
Mailing Address - Country:US
Mailing Address - Phone:520-241-3183
Mailing Address - Fax:602-866-0684
Practice Address - Street 1:2250 N CRAYCROFT RD
Practice Address - Street 2:STE 2200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2802
Practice Address - Country:US
Practice Address - Phone:520-241-3183
Practice Address - Fax:520-546-3433
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12217207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0725850OtherBLUE CROSS/BLUE SHIELD
AZ263773Medicaid
72581Medicare ID - Type Unspecified
AZ263773Medicaid