Healthcare Provider Details

I. General information

NPI: 1457320731
Provider Name (Legal Business Name): JEFFERY ALAN MILLER IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5428 MACQUEEN DR
VIRGINIA BEACH VA
23464-7722
US

IV. Provider business mailing address

5428 MACQUEEN DR
VIRGINIA BEACH VA
23464-7722
US

V. Phone/Fax

Practice location:
  • Phone: 757-965-5225
  • Fax:
Mailing address:
  • Phone: 757-965-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: