Provider Demographics
NPI:1790702207
Name:MILLER, TODD R (DPM)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:IA
Mailing Address - Zip Code:50220
Mailing Address - Country:US
Mailing Address - Phone:515-465-5688
Mailing Address - Fax:515-465-5634
Practice Address - Street 1:612 10TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:IA
Practice Address - Zip Code:50220
Practice Address - Country:US
Practice Address - Phone:515-465-5688
Practice Address - Fax:515-465-5634
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00643213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0137760Medicaid
IA0137760Medicaid
U61434Medicare UPIN
53875Medicare ID - Type Unspecified
IA1139620001Medicare PIN