Healthcare Provider Details

I. General information

NPI: 1255774683
Provider Name (Legal Business Name): MATTHEW DOUGLAS MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 ILLINOIS ST STE LL050
CARMEL IN
46032-3015
US

IV. Provider business mailing address

550 UNIVERSITY BLVD RM 663
INDIANAPOLIS IN
46202-5149
US

V. Phone/Fax

Practice location:
  • Phone: 317-617-4808
  • Fax: 317-222-2129
Mailing address:
  • Phone: 317-274-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number01090475A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01090475A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2018-02838
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: