Provider Demographics
NPI:1982839296
Name:MILLER, EVAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:T
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4725 STATESMEN DR
Practice Address - Street 2:STE. C-D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-5644
Practice Address - Country:US
Practice Address - Phone:317-577-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014750A390200000X
IN01069212A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430B69OtherMEDICARE PTAN
INQ00166434OtherRAILROAD PTAN
IN201067880Medicaid