Provider Demographics
NPI:1518693902
Name:MILLER, MALLORY (OD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BEACON ST APT 12A
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-1354
Mailing Address - Country:US
Mailing Address - Phone:724-797-7926
Mailing Address - Fax:
Practice Address - Street 1:77 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-1908
Practice Address - Country:US
Practice Address - Phone:617-227-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist