Provider Demographics
NPI:1841245339
Name:MILLER, JON M (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:140 STOLLINGS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-4035
Mailing Address - Country:US
Mailing Address - Phone:304-752-4594
Mailing Address - Fax:304-752-5629
Practice Address - Street 1:140 STOLLINGS AVE STE 3
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4035
Practice Address - Country:US
Practice Address - Phone:304-752-4594
Practice Address - Fax:304-752-5629
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV1298208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVF05878Medicare UPIN