Provider Demographics
NPI:1245402882
Name:DENNIS R MILLER, OD
Entity Type:Organization
Organization Name:DENNIS R MILLER, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-8855
Mailing Address - Street 1:101 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-6631
Mailing Address - Country:US
Mailing Address - Phone:219-326-8855
Mailing Address - Fax:
Practice Address - Street 1:101 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-6631
Practice Address - Country:US
Practice Address - Phone:219-326-8855
Practice Address - Fax:219-326-8855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200495330Medicaid
IN200495330AMedicaid
IN200495330Medicaid
IN4172770001Medicare NSC