Provider Demographics
NPI:1306822903
Name:MILLER, PRESTON ROY (MD)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:ROY
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-3813
Practice Address - Fax:336-716-5537
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500410208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
7600660OtherAETNA
NC128WXOtherBCBS
G44142Medicare UPIN
NCA7779OtherMEDCOST
SCQ0041BMedicaid
NC2221643EMedicare PIN
NC89128WXMedicaid
VA7312148Medicaid
NC41131OtherPARTNERS
WV2003672000Medicaid