Healthcare Provider Details

I. General information

NPI: 1003817263
Provider Name (Legal Business Name): EDWARD JOHN MILLER JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 5TH ST
DOUGLAS AZ
85607-2859
US

IV. Provider business mailing address

101 COLE AVE
BISBEE AZ
85603-1327
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-7659
  • Fax: 520-364-8541
Mailing address:
  • Phone: 520-432-6481
  • Fax: 520-432-5082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1279
License Number StateVI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02480
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: