Provider Demographics
NPI:1013916972
Name:MILLER, DAVID ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ETHAN
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 1:400 S MCCASLIN BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9701
Mailing Address - Country:US
Mailing Address - Phone:720-279-9682
Mailing Address - Fax:720-279-9687
Practice Address - Street 1:400 S MCCASLIN BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9701
Practice Address - Country:US
Practice Address - Phone:720-279-9682
Practice Address - Fax:720-279-9687
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00433942084P0800X
CO43394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC805046OtherMEDICARE PTAN
COC805046OtherMEDICARE PTAN