Healthcare Provider Details

I. General information

NPI: 1548451610
Provider Name (Legal Business Name): KEVIN L MILLER MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SAN GABRIEL VILLAGE BLVD STE 105
GEORGETOWN TX
78626-5594
US

IV. Provider business mailing address

700 SAN GABRIEL VILLAGE BLVD STE 105
GEORGETOWN TX
78626-5594
US

V. Phone/Fax

Practice location:
  • Phone: 512-819-9910
  • Fax: 512-819-9970
Mailing address:
  • Phone: 512-819-9910
  • Fax: 512-819-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberL1393
License Number StateTX

VIII. Authorized Official

Name: DR. KEVIN L MILLER
Title or Position: PRESIDENT
Credential: MD
Phone: 512-819-9910