Provider Demographics
NPI:1700848264
Name:MILLER, EDWARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
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 1:635 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9003
Mailing Address - Country:US
Mailing Address - Phone:530-926-5990
Mailing Address - Fax:
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10363207X00000X
CAG27556207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G275560OtherBLUE SHIELD
CA00G275560Medicaid
CA00G275560OtherBLUE CROSS
OR006313Medicaid
CA00G275560Medicare ID - Type Unspecified
CA00G275560OtherBLUE CROSS
OR006313Medicaid