Healthcare Provider Details

I. General information

NPI: 1457891590
Provider Name (Legal Business Name): SCOTT MILLER, OD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 W APACHE TRL
APACHE JUNCTION AZ
85120-5204
US

IV. Provider business mailing address

2555 W APACHE TRL
APACHE JUNCTION AZ
85120-5204
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-9557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2168
License Number StateAZ

VIII. Authorized Official

Name: SCOTT MILLER
Title or Position: OPTOMETRIST
Credential: OD
Phone: 480-983-9557