Healthcare Provider Details

I. General information

NPI: 1821065145
Provider Name (Legal Business Name): DUANE MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2006
Last Update Date: 02/15/2020
Certification Date: 02/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 N 95TH AVE APT 1022
GLENDALE AZ
85305-1352
US

IV. Provider business mailing address

7455 N 95TH AVE APT 1022
GLENDALE AZ
85305-1352
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-5875
  • Fax:
Mailing address:
  • Phone: 574-364-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number54412
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01027831
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010029956
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAIL ROAD MEDICARE
# 2
Identifier100145690
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 3
Identifier102669220
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 4
Identifier000000082220
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: