Provider Demographics
NPI:1376527275
Name:MILLER, MARVIN BRADLEY (DO)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:BRADLEY
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 HILLTOP DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5891
Mailing Address - Country:US
Mailing Address - Phone:817-596-0109
Mailing Address - Fax:817-594-3777
Practice Address - Street 1:945 HILLTOP DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5891
Practice Address - Country:US
Practice Address - Phone:817-596-0109
Practice Address - Fax:817-594-3777
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6449207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031748901Medicaid
TX00A69NMedicare PIN
TX031748901Medicaid