Provider Demographics
NPI:1205938271
Name:MILLER, MARK D (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
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 1:19905 WINDSOR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-4328
Mailing Address - Country:US
Mailing Address - Phone:175-578-9873
Mailing Address - Fax:317-773-1781
Practice Address - Street 1:16865 CLOVER RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-3640
Practice Address - Country:US
Practice Address - Phone:317-773-1981
Practice Address - Fax:317-773-1781
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8807152W00000X
IN18002264152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN857280Medicare ID - Type Unspecified