Healthcare Provider Details

I. General information

NPI: 1265876106
Provider Name (Legal Business Name): MARK DANIEL MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-4271
  • Fax: 859-258-4418
Mailing address:
  • Phone: 859-258-6200
  • Fax: 859-258-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number28222
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTP657
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number58412
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: