Healthcare Provider Details

I. General information

NPI: 1740637446
Provider Name (Legal Business Name): JOHN MARK MILLER D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429
US

IV. Provider business mailing address

3131 NEWMARK DR STE 220
MIAMISBURG OH
45342-5400
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-8166
  • Fax: 937-395-8347
Mailing address:
  • Phone: 937-436-4658
  • Fax: 937-436-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number34.013250
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.013250
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021-02402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: