Healthcare Provider Details

I. General information

NPI: 1770565251
Provider Name (Legal Business Name): CHARLES LUTHER MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SHREWSBURY PLAZA
SHREWSBURY NJ
07702-4332
US

IV. Provider business mailing address

PO BOX 8519
RED BANK NJ
07701-8519
US

V. Phone/Fax

Practice location:
  • Phone: 732-542-2124
  • Fax: 732-460-0496
Mailing address:
  • Phone: 732-460-9840
  • Fax: 732-460-9848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA2361500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number25MA2361500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: