Healthcare Provider Details

I. General information

NPI: 1487613543
Provider Name (Legal Business Name): THEODORE MARSHALL MILLER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 3886 AKONI PULE HWY SUITE #5
KAPAAU HI
96755-0053
US

IV. Provider business mailing address

PO BOX 53
KAPAAU HI
96755-0053
US

V. Phone/Fax

Practice location:
  • Phone: 808-889-0044
  • Fax: 808-884-5134
Mailing address:
  • Phone: 808-889-0044
  • Fax: 808-884-5134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number218
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: