Provider Demographics
NPI:1285682625
Name:MILLER, JEFFREY WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:330 N WABASH AVE STE 370
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2678
Practice Address - Country:US
Practice Address - Phone:765-660-7500
Practice Address - Fax:765-662-4724
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001695208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200321850AMedicaid
IN000000897778OtherANTHEM
ING19961Medicare UPIN
IN200321850AMedicaid
IN177700Medicare ID - Type Unspecified