Healthcare Provider Details

I. General information

NPI: 1053638064
Provider Name (Legal Business Name): MOLLIE T MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 PHAY AVE
CANON CITY CO
81212-2301
US

IV. Provider business mailing address

DEPT 1057
DENVER CO
80291-1057
US

V. Phone/Fax

Practice location:
  • Phone: 719-285-2700
  • Fax: 719-285-2455
Mailing address:
  • Phone: 303-486-5500
  • Fax: 303-486-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number48291
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: