Healthcare Provider Details

I. General information

NPI: 1881647139
Provider Name (Legal Business Name): MARK EDMUND MILLER II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE 205
PASADENA CA
91105-3150
US

IV. Provider business mailing address

800 FAIRMOUNT AVE 205
PASADENA CA
91105-3150
US

V. Phone/Fax

Practice location:
  • Phone: 626-405-1513
  • Fax:
Mailing address:
  • Phone: 626-405-1513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA76869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: