Healthcare Provider Details

I. General information

NPI: 1437385895
Provider Name (Legal Business Name): DARELL R MILLER CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E HOUSTON ST
TYLER TX
75702-8218
US

IV. Provider business mailing address

312 E HOUSTON ST
TYLER TX
75702-8218
US

V. Phone/Fax

Practice location:
  • Phone: 903-535-5011
  • Fax: 903-535-5000
Mailing address:
  • Phone: 903-535-5011
  • Fax: 903-535-5000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberPF0189
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: