Provider Demographics
NPI:1538119060
Name:MILLER, ROGER KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:KEVIN
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 1:1001 E SUPERIOR ST
Mailing Address - Street 2:STE L201
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-7980
Mailing Address - Fax:
Practice Address - Street 1:1001 E SUPERIOR ST
Practice Address - Street 2:STE L201
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2207
Practice Address - Country:US
Practice Address - Phone:218-249-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35066208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN128592100Medicaid
MNB74106Medicare UPIN
MN128592100Medicaid