Healthcare Provider Details

I. General information

NPI: 1740525195
Provider Name (Legal Business Name): JONATHAN G MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 W UNIVERSITY AVE SUITE 122
GEORGETOWN TX
78628-5340
US

IV. Provider business mailing address

1013 W UNIVERSITY AVE SUITE 122
GEORGETOWN TX
78628-5340
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-1100
  • Fax: 512-868-1105
Mailing address:
  • Phone: 512-868-1100
  • Fax: 512-868-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number11150
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: