Provider Demographics
NPI:1821167404
Name:MILLER, MARK DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6230 N DURANGO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-3916
Mailing Address - Country:US
Mailing Address - Phone:702-737-3937
Mailing Address - Fax:702-737-8860
Practice Address - Street 1:6230 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3916
Practice Address - Country:US
Practice Address - Phone:702-737-3937
Practice Address - Fax:702-737-8860
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV279152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502000Medicaid
NV002502000Medicaid
NV39276Medicare ID - Type Unspecified