Healthcare Provider Details

I. General information

NPI: 1598758351
Provider Name (Legal Business Name): MARC L MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 SANTA ROSA DR STE 301
KINGMAN AZ
86401-2311
US

IV. Provider business mailing address

51 SEWALL ST
PORTLAND ME
04102-2643
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-8730
  • Fax: 928-681-8731
Mailing address:
  • Phone: 207-774-5761
  • Fax: 207-874-7478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD11083
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number59883
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: