Provider Demographics
NPI:1396847398
Name:MILLER, JON W (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:W
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:PO BOX 36218
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6218
Mailing Address - Country:US
Mailing Address - Phone:502-634-6767
Mailing Address - Fax:502-634-6775
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-634-6767
Practice Address - Fax:502-634-6775
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18436207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18436OtherKY LICENSE
KY64184369Medicaid
KYK103800Medicare PIN
KY18436OtherKY LICENSE
KY64184369Medicaid