Provider Demographics
NPI:1518078625
Name:MILLER, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2521
Mailing Address - Country:US
Mailing Address - Phone:732-294-9393
Mailing Address - Fax:732-446-5991
Practice Address - Street 1:1000 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2521
Practice Address - Country:US
Practice Address - Phone:732-294-9393
Practice Address - Fax:732-446-5991
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00220200213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5560209Medicaid
NJ004063Medicare ID - Type Unspecified
NJ5560209Medicaid
NJ6389500001Medicare NSC