Healthcare Provider Details

I. General information

NPI: 1003968058
Provider Name (Legal Business Name): RANDY KING MILLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25376 STATE HIGHWAY 39 STE 301
SHELL KNOB MO
65747-7343
US

IV. Provider business mailing address

3800 S NATIONAL AVE STE 540
SPRINGFIELD MO
65807-5209
US

V. Phone/Fax

Practice location:
  • Phone: 417-236-2680
  • Fax: 417-236-2683
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-269-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMO115530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: