Provider Demographics
NPI:1922079011
Name:MILLER, SCOTT R (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
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 1:3100 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1200
Mailing Address - Country:US
Mailing Address - Phone:616-534-8238
Mailing Address - Fax:616-534-4189
Practice Address - Street 1:3100 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1200
Practice Address - Country:US
Practice Address - Phone:616-534-8238
Practice Address - Fax:616-534-4189
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4074370Medicaid
MI4074370Medicaid
P10400002Medicare ID - Type Unspecified