Provider Demographics
NPI:1821212416
Name:DR JACK D MILLER LTD
Entity Type:Organization
Organization Name:DR JACK D MILLER LTD
Other - Org Name:DRS MILLER AND MILLER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:337-457-5277
Mailing Address - Street 1:350 MOOSA BLVD
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-3626
Mailing Address - Country:US
Mailing Address - Phone:337-457-5277
Mailing Address - Fax:337-457-5271
Practice Address - Street 1:350 MOOSA BLVD
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-3626
Practice Address - Country:US
Practice Address - Phone:337-457-5277
Practice Address - Fax:337-457-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA941-084T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1340952Medicaid
LA2105BOtherBLUE CROSS BLUE SHIELDPIN
LA0289830001OtherCIGNA GOVERMENT SERVICES
LA2105BOtherBLUE CROSS BLUE SHIELDPIN
LA5DB38Medicare PIN
LAT19415Medicare UPIN