Provider Demographics
NPI:1588636856
Name:MILLER, BEVERLY BUSHWICK (OD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:BUSHWICK
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BEVERLY
Other - Middle Name:MILLER
Other - Last Name:ROSENBLATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:30030 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2046
Mailing Address - Country:US
Mailing Address - Phone:949-495-3031
Mailing Address - Fax:949-495-9238
Practice Address - Street 1:30030 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2046
Practice Address - Country:US
Practice Address - Phone:949-495-3031
Practice Address - Fax:949-495-9238
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA 0681152W00000X
CA12963TPA152W00000X
FLOPC1430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD907716OtherBLOCK VISION
MD1223367OtherCAQH
MD271019OtherMDIPA/MAMSI
MDOP2260OtherEYEMED
DC89160001OtherBLUECROSS
MD1032476OtherAETNA
MD490518100Medicaid
MD00X237OtherCAREFIRST BC/BS
MD20-8901521OtherHEALTHNET/TRICARE
MD1223367OtherCAQH
MDOP2260OtherEYEMED