Provider Demographics
NPI:1598702110
Name:MILLER, KEVIN BURTUS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BURTUS
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-0309
Mailing Address - Country:US
Mailing Address - Phone:715-424-4141
Mailing Address - Fax:715-424-4152
Practice Address - Street 1:400 DEWEY STREET
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-424-4141
Practice Address - Fax:715-424-4152
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26000332B00000X
WI26000-20207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30577700Medicaid
WI30577700Medicaid
WI000072040Medicare PIN
WI0343180001Medicare NSC