Healthcare Provider Details

I. General information

NPI: 1104860246
Provider Name (Legal Business Name): RONALD MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ADDISON AVE W SUITE 100
TWIN FALLS ID
83301-5491
US

IV. Provider business mailing address

630 ADDISON AVE W SUITE 100
TWIN FALLS ID
83301-5491
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-4343
  • Fax: 208-734-9941
Mailing address:
  • Phone: 208-733-4343
  • Fax: 208-734-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM5473
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: