Provider Demographics
NPI:1134119399
Name:MILLER, AMY MARIE (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:900 E MORTON PL
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4529
Mailing Address - Country:US
Mailing Address - Phone:951-658-9409
Mailing Address - Fax:951-658-2057
Practice Address - Street 1:900 E MORTON PL
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4529
Practice Address - Country:US
Practice Address - Phone:951-658-9409
Practice Address - Fax:951-658-2057
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12648T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16682OtherMEDICAL EYE SERVICES ID#
CA48726OtherHEALTHNET VISION ID#
CA48726OtherHEALTHNET VISION ID#
CASD0126480Medicare ID - Type Unspecified