Provider Demographics
NPI:1831250711
Name:MILLER, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:DAVID
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1615 HOSPITAL PARKWAY
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022
Mailing Address - Country:US
Mailing Address - Phone:817-684-5106
Mailing Address - Fax:817-684-5120
Practice Address - Street 1:1615 HOSPITAL PARKWAY
Practice Address - Street 2:SUITE 306
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022
Practice Address - Country:US
Practice Address - Phone:817-684-5106
Practice Address - Fax:817-684-5120
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7189207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084655201Medicaid
D66981Medicare UPIN
TX00R07WMedicare ID - Type Unspecified