Healthcare Provider Details

I. General information

NPI: 1154996098
Provider Name (Legal Business Name): TREVOR MILLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

IV. Provider business mailing address

305 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6322
  • Fax:
Mailing address:
  • Phone: 575-622-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRO-2042
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2023-1087
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: