Provider Demographics
NPI:1861497612
Name:MILLER, DAVID L (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0556
Mailing Address - Country:US
Mailing Address - Phone:309-833-2868
Mailing Address - Fax:309-836-3779
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:STE 103
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-833-3536
Practice Address - Fax:309-836-5729
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104354Medicaid
IL110247080OtherRAILROAD MEDICARE
IL5532005OtherBLUE CROSS/BLUE SHIELD
IL067033OtherHEALTH ALLIANCE
IL067033OtherHEALTH ALLIANCE
H32235Medicare UPIN
IL213226Medicare ID - Type Unspecified