Provider Demographics
NPI:1457320731
Name:MILLER, JEFFERY ALAN (IDC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5428 MACQUEEN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7722
Mailing Address - Country:US
Mailing Address - Phone:757-965-5225
Mailing Address - Fax:
Practice Address - Street 1:5428 MACQUEEN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-7722
Practice Address - Country:US
Practice Address - Phone:757-965-5225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman