Provider Demographics
NPI:1629309562
Name:MILLER, JEREMY MICHAEL (NAVY IDC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 AVENIDA OLMEDA
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-4509
Mailing Address - Country:US
Mailing Address - Phone:757-375-6277
Mailing Address - Fax:
Practice Address - Street 1:7TH ESB BAS
Practice Address - Street 2:UNIT 42210
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96427-2210
Practice Address - Country:US
Practice Address - Phone:318-357-2671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman