Healthcare Provider Details

I. General information

NPI: 1942486055
Provider Name (Legal Business Name): MARK D MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 N OUTER 40 STE 200
CHESTERFIELD MO
63017-2152
US

IV. Provider business mailing address

14825 N OUTER 40 STE 200
CHESTERFIELD MO
63017-2152
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-2555
  • Fax:
Mailing address:
  • Phone: 314-336-2555
  • Fax: 314-336-2557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number116434
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: