Healthcare Provider Details

I. General information

NPI: 1720078264
Provider Name (Legal Business Name): THEODORE H MILLER M.D., PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 NORTH GRAND AVE. SUITE 101
FT. THOMAS KY
41075
US

IV. Provider business mailing address

40 N GRAND AVE STE 103
FORT THOMAS KY
41075-1765
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-4900
  • Fax: 859-781-3039
Mailing address:
  • Phone: 859-781-4900
  • Fax: 859-572-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number25084
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25084
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: