Provider Demographics
NPI:1710978473
Name:MILLER, BRIAN RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RICHARD
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 1:6349 W TRESTLE ST
Mailing Address - Street 2:UNIT #2
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8866
Mailing Address - Country:US
Mailing Address - Phone:208-687-5750
Mailing Address - Fax:
Practice Address - Street 1:15630 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8710
Practice Address - Country:US
Practice Address - Phone:208-687-0370
Practice Address - Fax:208-687-0470
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN