Provider Demographics
NPI:1588623490
Name:MILLER, EDWARD A JR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 357049
Mailing Address - Street 2:DEEP SUBMERGENCE UNIT
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92135-7049
Mailing Address - Country:US
Mailing Address - Phone:619-545-6962
Mailing Address - Fax:619-545-6868
Practice Address - Street 1:BLDG 497 MOFFETT RD
Practice Address - Street 2:DEEP SUBMERGENCE UNIT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135-7049
Practice Address - Country:US
Practice Address - Phone:619-545-0574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman