Provider Demographics
NPI:1912976770
Name:MILLER, MICHAEL LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840294
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0294
Mailing Address - Country:US
Mailing Address - Phone:888-344-1160
Mailing Address - Fax:972-331-3148
Practice Address - Street 1:4207 E COTTON CENTER BLVD # CC10
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-8893
Practice Address - Country:US
Practice Address - Phone:602-648-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43915207ZH0000X, 207ZP0102X
AZ005353207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121885900Medicaid
CO67175830Medicaid
UTZ2953Medicaid
MT149056Medicaid
MN826380900Medicaid
AZ977027Medicaid
D97927Medicare UPIN
AZ977027Medicaid
MT149056Medicaid