Provider Demographics
NPI:1972692457
Name:MILLER, RANDALL D (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:D
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 1:1001 NOBLE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4922
Mailing Address - Country:US
Mailing Address - Phone:907-353-4183
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 3406 ALDER STREET
Practice Address - Street 2:KAMISH CLINIC
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-0000
Practice Address - Country:US
Practice Address - Phone:907-353-4183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79045207Q00000X
AK5596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0384Medicaid
AKMD0384Medicaid
AKE17978Medicare UPIN
AKAM2111918OtherDEA
AKK160837Medicare PIN