Provider Demographics
NPI:1205045481
Name:MILLER, KELLY MICHAEL (IDC)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46-271 KAHUHIPA ST APT E109
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-6024
Mailing Address - Country:US
Mailing Address - Phone:808-271-5490
Mailing Address - Fax:
Practice Address - Street 1:COMMANDING OFFICER MEDICAL COMPANY
Practice Address - Street 2:CSSG-3 BOX 63067 MCBH
Practice Address - City:KANEOHE BAY
Practice Address - State:HI
Practice Address - Zip Code:96863
Practice Address - Country:US
Practice Address - Phone:808-257-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman