Provider Demographics
NPI:1447213624
Name:MILLER, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
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 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:1401 E VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4245
Practice Address - Country:US
Practice Address - Phone:918-426-0240
Practice Address - Fax:918-423-4051
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1324230001OtherPALMETTO DME
OK730710406020OtherBC/BS
OKD35047OtherSTERLING OPTION 1
OK100104840AMedicaid
OK731310891006OtherUNICARE
OK7313108931028OtherTRICARE SOUTH
OK0166707OtherUMWA
OK74502A010OtherCHAMPUS (WPS)
OKD35047OtherSTERLING OPTION 1
OK110181454Medicare PIN