Provider Demographics
NPI:1558441238
Name:MILLER, KENNETH D (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
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:PO BOX 95000 LB#7550
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:16 OLD BROOKSIDE ROAD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-895-4000
Practice Address - Fax:973-895-3310
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA34422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJIP099OtherOXFORD
NJ0736771010OtherCIGNA
NJ0920401Medicaid
NJ0920401Medicaid
NJIP099OtherOXFORD