Healthcare Provider Details

I. General information

NPI: 1053405746
Provider Name (Legal Business Name): DYREK EVERETH MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/14/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 DUPLIN STREET
KENANSVILLE NC
28349-2834
US

IV. Provider business mailing address

PO BOX 490
KENANSVILLE NC
28349
US

V. Phone/Fax

Practice location:
  • Phone: 910-275-0027
  • Fax: 910-296-0214
Mailing address:
  • Phone: 910-275-0027
  • Fax: 910-296-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number200300667
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: