Provider Demographics
NPI:1396739967
Name:MILLER, DARRELL M (MD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4421 NE ST JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2573
Mailing Address - Country:US
Mailing Address - Phone:360-695-9922
Mailing Address - Fax:360-695-1310
Practice Address - Street 1:406 SE 131ST AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4004
Practice Address - Country:US
Practice Address - Phone:360-253-2822
Practice Address - Fax:360-253-8642
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA15075207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8106502Medicaid
WAA08148Medicare UPIN
WA8106502Medicaid
WAG000681407Medicare PIN