Provider Demographics
NPI:1326073115
Name:MILLER, MICHAEL JAN (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 REPUBLIC PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4157
Mailing Address - Country:US
Mailing Address - Phone:972-270-7627
Mailing Address - Fax:972-270-7759
Practice Address - Street 1:1675 REPUBLIC PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6903
Practice Address - Country:US
Practice Address - Phone:972-270-7627
Practice Address - Fax:972-270-7759
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0425213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0018779101Medicaid
TX0018779101Medicaid
TXT14828Medicare UPIN
TX1292660001Medicare NSC