Provider Demographics
NPI:1558369215
Name:MILLER, DEBRA R (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:R
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5917
Mailing Address - Country:US
Mailing Address - Phone:860-447-1419
Mailing Address - Fax:860-442-2604
Practice Address - Street 1:53 GRANITE ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5917
Practice Address - Country:US
Practice Address - Phone:860-447-1419
Practice Address - Fax:860-442-2604
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036169207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001361691Medicaid
CT001361691Medicaid
CT070000370Medicare ID - Type Unspecified