Provider Demographics
NPI:1710764212
Name:MILLER, MICHAEL THOMAS
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 W SW 59TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-2298
Mailing Address - Country:US
Mailing Address - Phone:405-802-4746
Mailing Address - Fax:
Practice Address - Street 1:1750 W SW 59TH ST
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-2298
Practice Address - Country:US
Practice Address - Phone:405-802-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist