Provider Demographics
NPI:1366505364
Name:MILLER, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4158
Practice Address - Country:US
Practice Address - Phone:928-639-6180
Practice Address - Fax:928-639-6698
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5414499-1205207ZP0102X
AZ36457207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ264578Medicaid
AZ264578Medicaid