Provider Demographics
NPI:1225440274
Name:MILLER, DUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
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 1:1455 FARR RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-9738
Mailing Address - Country:US
Mailing Address - Phone:231-638-7319
Mailing Address - Fax:
Practice Address - Street 1:1455 FARR RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9738
Practice Address - Country:US
Practice Address - Phone:231-737-0411
Practice Address - Fax:231-739-8502
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301105821208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225440274Medicaid