Provider Demographics
NPI:1558474130
Name:MILLER, MARK L (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 FLOYD DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008-8261
Mailing Address - Country:US
Mailing Address - Phone:502-732-1082
Mailing Address - Fax:
Practice Address - Street 1:329 FLOYD DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8261
Practice Address - Country:US
Practice Address - Phone:502-732-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000526905OtherANTHEM
KY64123722Medicaid
KY50014320OtherPASSPORT
KY2831247000OtherPASSPORT ADVANTAGE
KY64123722Medicaid
KY00528004Medicare PIN