Provider Demographics
NPI:1619206034
Name:DEBRA R MILLER MD LLC
Entity Type:Organization
Organization Name:DEBRA R MILLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-447-1419
Mailing Address - Street 1:53 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5945
Mailing Address - Country:US
Mailing Address - Phone:860-447-1419
Mailing Address - Fax:860-442-2604
Practice Address - Street 1:53 GRANITE ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5945
Practice Address - Country:US
Practice Address - Phone:860-447-1419
Practice Address - Fax:860-442-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001361691Medicaid
070000370Medicare PIN
E94678Medicare UPIN