Healthcare Provider Details

I. General information

NPI: 1720509458
Provider Name (Legal Business Name): GRANT THOMAS MILLER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8362 GRAND AVE
RIVER GROVE IL
60171
US

IV. Provider business mailing address

2951 N TALMAN AVE APT 3F
CHICAGO IL
60618-7837
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-1100
  • Fax:
Mailing address:
  • Phone: 812-767-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011216
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number046011216
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: