Provider Demographics
NPI:1376838375
Name:MILLER, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
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 1:323 E RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6864
Mailing Address - Country:US
Mailing Address - Phone:208-367-5300
Mailing Address - Fax:208-367-2692
Practice Address - Street 1:323 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6864
Practice Address - Country:US
Practice Address - Phone:208-367-5300
Practice Address - Fax:208-367-2692
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12426207P00000X
390200000X
ORMD183370207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program