Healthcare Provider Details

I. General information

NPI: 1649320441
Provider Name (Legal Business Name): MILLER OPTOMETRISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 10/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 E 3RD ST
DELPHOS OH
45833-1761
US

IV. Provider business mailing address

PO BOX 159
DELPHOS OH
45833-0159
US

V. Phone/Fax

Practice location:
  • Phone: 419-692-0010
  • Fax: 419-695-4533
Mailing address:
  • Phone: 419-692-0010
  • Fax: 419-695-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4625OH
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3030H
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0157888
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier0265510
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. JOHN EUGENE GRONE
Title or Position: CEO
Credential: O.D.
Phone: 419-692-0010