Provider Demographics
NPI:1225066418
Name:MILLER, KENNETH JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
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 1:32 BAY FRONT PL
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-1791
Mailing Address - Country:US
Mailing Address - Phone:614-832-8392
Mailing Address - Fax:888-383-3873
Practice Address - Street 1:32 BAY FRONT PL
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23664-1791
Practice Address - Country:US
Practice Address - Phone:614-832-8392
Practice Address - Fax:888-383-3873
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0495172084P0800X
CAC411662084P0800X
VA01012539922084P0800X
SCMD331252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2205214Medicaid
A37543Medicare UPIN
OHMI4013111Medicare ID - Type Unspecified