Provider Demographics
NPI:1457477150
Name:MILLER, JON MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
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 1:2000 WARRINGTON WAY STE 160
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6401
Mailing Address - Country:US
Mailing Address - Phone:502-426-1500
Mailing Address - Fax:502-425-6803
Practice Address - Street 1:2000 WARRINGTON WAY STE 160
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6401
Practice Address - Country:US
Practice Address - Phone:502-426-1500
Practice Address - Fax:502-425-6803
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG03783Medicare UPIN