Healthcare Provider Details

I. General information

NPI: 1174511042
Provider Name (Legal Business Name): DAVID W MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 S ASPEN
BROKEN ARROW OK
74127-9020
US

IV. Provider business mailing address

DEPT. 672
TULSA OK
74182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 918-286-6331
  • Fax:
Mailing address:
  • Phone: 866-321-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number20875
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier100021790B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: