Provider Demographics
NPI:1154468775
Name:MILLER, DANIEL RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYMOND
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 1:321 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4220
Mailing Address - Country:US
Mailing Address - Phone:208-791-6718
Mailing Address - Fax:208-743-0528
Practice Address - Street 1:321 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4220
Practice Address - Country:US
Practice Address - Phone:208-791-6718
Practice Address - Fax:208-743-0528
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA,OO2456100Medicaid
ID1109873Medicare ID - Type Unspecified
IA,OO2456100Medicaid