Provider Demographics
NPI:1477540318
Name:MILLER, DAVID WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1784
Mailing Address - Country:US
Mailing Address - Phone:309-829-5311
Mailing Address - Fax:309-827-8027
Practice Address - Street 1:2475 N MONROE ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3941
Practice Address - Country:US
Practice Address - Phone:217-875-5900
Practice Address - Fax:217-875-5600
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
103363001OtherDMERC
P00104657OtherRAILROAD MEDICARE
05832035OtherBCBS
P00104657OtherRAILROAD MEDICARE
05832035OtherBCBS