Provider Demographics
NPI:1326048802
Name:MILLER, THOMAS LEE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
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 1:1500 W MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-8605
Mailing Address - Country:US
Mailing Address - Phone:260-665-8494
Mailing Address - Fax:
Practice Address - Street 1:1500 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-8605
Practice Address - Country:US
Practice Address - Phone:260-665-8494
Practice Address - Fax:260-668-5690
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200185720A261QR1300X
IN01033506A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100225670Medicaid
IN200185720AMedicaid
IND67852Medicare UPIN
IN100225670Medicaid
IN200185720AMedicaid