Provider Demographics
NPI:1164424099
Name:MILLER, KENNETH MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARC
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 780217
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-0217
Mailing Address - Country:US
Mailing Address - Phone:718-639-8827
Mailing Address - Fax:718-639-8811
Practice Address - Street 1:311 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0903
Practice Address - Country:US
Practice Address - Phone:212-996-6633
Practice Address - Fax:212-996-6677
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210303207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1V7471OtherEMPIRE BLUE CROSS BLUE SH
NY2595177OtherGHI
NYP2479763OtherOXFORD HEALTH PLAN
NY4C0580OtherHEALTH PLAN OF NEW YORK
NY02133062Medicaid
NYMK0303OtherATLANTIS
NYP2479763OtherOXFORD HEALTH PLAN
NYG58017Medicare UPIN