Provider Demographics
NPI:1831161363
Name:MILLER, NATHAN G (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:G
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 S WASATCH BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3511
Mailing Address - Country:US
Mailing Address - Phone:918-786-7780
Mailing Address - Fax:
Practice Address - Street 1:6440 S WASATCH BLVD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84121-3511
Practice Address - Country:US
Practice Address - Phone:918-786-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8858699-12052086S0122X
FLME940052086S0122X
OK249202086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W0850OtherBC/BS OF TEXAS
OK200265920AMedicaid
OK100747570FMedicaid
OKDC3959OtherRR MEDICARE
OKP01126512OtherRR MEDICARE
TX8W0850OtherBC/BS OF TEXAS
TX8F4429Medicare PIN
OKDC3959OtherRR MEDICARE
TX8F2249Medicare PIN
TX8F4425Medicare PIN
TX8F2252Medicare PIN
TX8F4427Medicare PIN
OKP01126512OtherRR MEDICARE
OK400522488Medicare PIN
OK244635501Medicare PIN