Provider Demographics
NPI:1972500346
Name:MILLER, TIMOTHY E (CPO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:MILLER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 YANKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52765-9303
Mailing Address - Country:US
Mailing Address - Phone:563-785-6145
Mailing Address - Fax:
Practice Address - Street 1:4505 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1641
Practice Address - Country:US
Practice Address - Phone:563-344-4206
Practice Address - Fax:563-344-4209
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL421429042001Medicaid
IA0118281Medicaid
IL0936870001Medicare ID - Type Unspecified
IL421429042001Medicaid