Provider Demographics
NPI:1821059395
Name:MILLER, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:700 SAN GABRIEL VILLAGE BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5594
Mailing Address - Country:US
Mailing Address - Phone:512-819-9910
Mailing Address - Fax:512-819-9970
Practice Address - Street 1:700 SAN GABRIEL VILLAGE BLVD
Practice Address - Street 2:STE 105
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5594
Practice Address - Country:US
Practice Address - Phone:512-819-9910
Practice Address - Fax:512-819-9970
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL1393207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7524367OtherAETNA ID
TX0034KLOtherBLUE CROSS
TX0034KLOtherBLUE CROSS
TX7524367OtherAETNA ID