Provider Demographics
NPI:1760406771
Name:MILLER, LON (MD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:
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 1:4120 W SOFT WIND DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-4000
Mailing Address - Country:US
Mailing Address - Phone:509-336-3775
Mailing Address - Fax:623-547-7196
Practice Address - Street 1:4120 W SOFT WIND DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-4000
Practice Address - Country:US
Practice Address - Phone:509-336-3775
Practice Address - Fax:623-547-7196
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6077207P00000X
WAMD00030099207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8167116Medicaid
ID003836400Medicaid
ID1127093Medicare ID - Type Unspecified
IDA35667Medicare UPIN
WA8864726Medicare PIN
ID003836400Medicaid