Provider Demographics
NPI:1952325870
Name:MILLER, MICHAEL DWAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DWAYNE
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 1:258 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1638
Mailing Address - Country:US
Mailing Address - Phone:317-831-0725
Mailing Address - Fax:317-831-0734
Practice Address - Street 1:258 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1638
Practice Address - Country:US
Practice Address - Phone:317-831-0725
Practice Address - Fax:317-831-0734
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002514A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1250520001Medicare NSC
INU20172Medicare UPIN
IN069530Medicare ID - Type Unspecified