Provider Demographics
NPI:1548403074
Name:MILLER, BRIAN COTTRELL (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:COTTRELL
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 1:7232 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2222
Mailing Address - Country:US
Mailing Address - Phone:260-436-7205
Mailing Address - Fax:260-432-1339
Practice Address - Street 1:7232 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2222
Practice Address - Country:US
Practice Address - Phone:260-436-7205
Practice Address - Fax:260-432-1339
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072270A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201107670Medicaid
IN137910001Medicare PIN
IN201107670Medicaid