Provider Demographics
NPI:1568610616
Name:MILLER, JOHN MARK (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:MILLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 CENTENNIAL BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0586
Mailing Address - Country:US
Mailing Address - Phone:850-656-1837
Mailing Address - Fax:850-877-2917
Practice Address - Street 1:2615 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0586
Practice Address - Country:US
Practice Address - Phone:850-656-1837
Practice Address - Fax:850-877-2917
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24248225100000X
TX1102622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist