Provider Demographics
NPI:1275685554
Name:MILLER, JOHN DAVID (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 SHALLOWFORD RD
Mailing Address - Street 2:SUITE F-1
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:770-640-7800
Mailing Address - Fax:770-640-7779
Practice Address - Street 1:4343 SHALLOWFORD RD
Practice Address - Street 2:SUITE F-1
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:770-640-7800
Practice Address - Fax:770-640-7779
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU06246Medicare UPIN