Provider Demographics
NPI:1689025827
Name:MILLER, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1170 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6101
Mailing Address - Country:US
Mailing Address - Phone:541-779-7331
Mailing Address - Fax:402-559-8940
Practice Address - Street 1:1170 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6101
Practice Address - Country:US
Practice Address - Phone:541-779-7331
Practice Address - Fax:541-779-3522
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD204536207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500793096Medicaid