Healthcare Provider Details

I. General information

NPI: 1922100650
Provider Name (Legal Business Name): JACOB ROY MILLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 N 16TH ST
PHOENIX AZ
85016-5917
US

IV. Provider business mailing address

3840 N 16TH ST
PHOENIX AZ
85016-5917
US

V. Phone/Fax

Practice location:
  • Phone: 602-232-6066
  • Fax:
Mailing address:
  • Phone: 602-232-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1526
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: