Provider Demographics
NPI:1255528873
Name:MILLER, MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:450 S CAMINO DEL RIO
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-6856
Mailing Address - Country:US
Mailing Address - Phone:970-247-3613
Mailing Address - Fax:970-247-5823
Practice Address - Street 1:450 S CAMINO DEL RIO
Practice Address - Street 2:SUITE 101
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-6856
Practice Address - Country:US
Practice Address - Phone:970-247-3613
Practice Address - Fax:970-247-5823
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08918377Medicaid
CO08918377Medicaid
COCF0933Medicare PIN