Provider Demographics
NPI:1881629327
Name:MILLER, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3045 E ST LUKES ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3507
Mailing Address - Country:US
Mailing Address - Phone:208-288-2020
Mailing Address - Fax:208-288-2015
Practice Address - Street 1:3045 E ST LUKES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3507
Practice Address - Country:US
Practice Address - Phone:208-288-2020
Practice Address - Fax:208-288-2021
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-12-12
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Provider Licenses
StateLicense IDTaxonomies
IDM7853207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5854480001Medicare NSC
H02126Medicare UPIN