Provider Demographics
NPI:1457321333
Name:MILLER, KEVIN T (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
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:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-0435
Mailing Address - Country:US
Mailing Address - Phone:541-549-9606
Mailing Address - Fax:541-278-8379
Practice Address - Street 1:354 ADAMS
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-549-9606
Practice Address - Fax:541-549-0593
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD021606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134147Medicaid
OR108912Medicare ID - Type Unspecified
OR134147Medicaid