Provider Demographics
NPI:1558656090
Name:MARK MILLER MD INC
Entity Type:Organization
Organization Name:MARK MILLER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:626-405-1513
Mailing Address - Street 1:510 W CENTRAL AVE
Mailing Address - Street 2:STE A
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3032
Mailing Address - Country:US
Mailing Address - Phone:714-996-1633
Mailing Address - Fax:714-996-9267
Practice Address - Street 1:800 FAIRMOUNT AVE
Practice Address - Street 2:STE 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3150
Practice Address - Country:US
Practice Address - Phone:626-405-1513
Practice Address - Fax:626-449-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76869207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty