Provider Demographics
NPI:1720377864
Name:MATT MILLER OD PA
Entity Type:Organization
Organization Name:MATT MILLER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-406-4362
Mailing Address - Street 1:3963 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3202
Mailing Address - Country:US
Mailing Address - Phone:817-237-7153
Mailing Address - Fax:817-237-7123
Practice Address - Street 1:3963 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3202
Practice Address - Country:US
Practice Address - Phone:817-237-7153
Practice Address - Fax:817-237-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB135295Medicare PIN