Provider Demographics
NPI:1154303725
Name:MILLER, GRADY F (DO)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:F
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 FM 2342
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:TX
Practice Address - Zip Code:78639-6010
Practice Address - Country:US
Practice Address - Phone:325-388-9400
Practice Address - Fax:325-388-9422
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045399504Medicaid
TX82348OtherSCOTT & WHITE
TX045399503Medicaid
TX130875101OtherFIRSTCARE
TX8F9832OtherBCBS
TXTXB129656Medicare PIN
TX8398K4Medicare PIN
H09637Medicare UPIN
TX045399503Medicaid