Provider Demographics
NPI:1811192313
Name:MILLER, MARK HERMAN (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HERMAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12011 LEE JACKSON HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-352-0706
Mailing Address - Fax:703-352-6954
Practice Address - Street 1:12011 LEE JACKSON HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-352-0706
Practice Address - Fax:703-352-6954
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD44280001OtherBCBS
DC44280001OtherBCBS
0089918Medicare ID - Type Unspecified