Provider Demographics
NPI:1811255201
Name:MILLER, JERRY PAUL III
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:PAUL
Last Name:MILLER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:PAUL
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4701 CEDAR COALS CT # A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9072
Mailing Address - Country:US
Mailing Address - Phone:985-515-4779
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5275
Practice Address - Country:US
Practice Address - Phone:573-814-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA304573208VP0014X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program