Healthcare Provider Details

I. General information

NPI: 1861753618
Provider Name (Legal Business Name): JESSE LEE MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 PLEASANT VALLEY RD
OWENSBORO KY
42303-9811
US

IV. Provider business mailing address

6225 N STATE HIGHWAY 161 SUITE 200
IRVING TX
75038-2223
US

V. Phone/Fax

Practice location:
  • Phone: 270-417-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number49589
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: