Healthcare Provider Details

I. General information

NPI: 1619317500
Provider Name (Legal Business Name): RICKY MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

1924 ALCOA HWY # U-11
KNOXVILLE TN
37920-1511
US

V. Phone/Fax

Practice location:
  • Phone: 985-435-4831
  • Fax: 985-449-2585
Mailing address:
  • Phone: 865-305-9230
  • Fax: 865-305-8894

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 Number322505
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: