Healthcare Provider Details

I. General information

NPI: 1952721151
Provider Name (Legal Business Name): JONATHAN JORDAN MILLER M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2014
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

IV. Provider business mailing address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

V. Phone/Fax

Practice location:
  • Phone: 888-226-4353
  • Fax:
Mailing address:
  • Phone: 901-595-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56520
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: