Provider Demographics
NPI:1942390208
Name:MILLER, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 OAK ST
Mailing Address - Street 2:SUITE 205W
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-583-4440
Mailing Address - Fax:508-583-7401
Practice Address - Street 1:830 OAK ST
Practice Address - Street 2:SUITE 205W
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1168
Practice Address - Country:US
Practice Address - Phone:508-583-4440
Practice Address - Fax:508-583-7401
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54240207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3002543Medicaid
MA054240Medicare UPIN
MAJ04951Medicare UPIN
MAB74549Medicare UPIN
MAJ04951Medicare ID - Type UnspecifiedMEDICARE PROV #
MA2500784Medicare UPIN
MA67564Medicare UPIN
MASF040069Medicare UPIN
MA2383468Medicare UPIN
MA0003421Medicare UPIN
MA3951Medicare UPIN
MAP00082140Medicare ID - Type UnspecifiedMEDICARE RR
MAB20563801Medicare UPIN
MA3002543Medicaid