Provider Demographics
NPI:1679621130
Name:MILLER, CA (OD)
Entity Type:Individual
Prefix:
First Name:CA
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 CAPITAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9358
Mailing Address - Country:US
Mailing Address - Phone:269-979-1561
Mailing Address - Fax:269-979-1561
Practice Address - Street 1:4275 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9358
Practice Address - Country:US
Practice Address - Phone:269-979-1561
Practice Address - Fax:269-979-1561
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A36524OtherPTAN
MI5048562Medicaid
MI0378720001Medicare NSC
MI5048562Medicaid
MIWY5748Medicare PIN