Provider Demographics
NPI:1770500274
Name:MILLER, GWEN GIANNINI (OD)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:GIANNINI
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:MARIE
Other - Last Name:GIANNINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21375 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2122
Mailing Address - Country:US
Mailing Address - Phone:440-333-7346
Mailing Address - Fax:440-333-0273
Practice Address - Street 1:16400 HILLIARD RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5610
Practice Address - Country:US
Practice Address - Phone:216-228-1800
Practice Address - Fax:440-333-0273
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5258/T2164152W00000X
PAOE008485T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2860999Medicaid
OHP00721313OtherRAILROAD MEDICARE
OH1275512709OtherPRACTICE NPI
OH2860999Medicaid
OHP00721313OtherRAILROAD MEDICARE