Provider Demographics
NPI:1669804902
Name:MILLER, MINDY NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:MINDY
Middle Name:NICOLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MINDY
Other - Middle Name:NICOLE
Other - Last Name:HOFFMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:15933 CLAYTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:2645 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2302
Practice Address - Country:US
Practice Address - Phone:618-767-5100
Practice Address - Fax:618-767-5101
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist