Provider Demographics
NPI:1477817799
Name:MILLER, MATTHEW A (MD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1211 SOUTH GLOSTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:1211 SOUTH GLOSTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:662-767-4204
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2577207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06835533Medicaid