Provider Demographics
NPI:1164419685
Name:MILLER, MICHAEL GLEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLEN
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 1:3021 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2369
Mailing Address - Country:US
Mailing Address - Phone:360-802-5580
Mailing Address - Fax:360-825-6536
Practice Address - Street 1:3021 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2369
Practice Address - Country:US
Practice Address - Phone:360-802-5580
Practice Address - Fax:360-825-6536
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407172207X00000X
WAMD 60287490207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery