=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588636856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEVERLY BUSHWICK MILLER OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 08/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30030 TOWN CENTER DR
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-495-3031
-----------------------------------------------------
Fax | 949-495-9238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30030 TOWN CENTER DR
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-495-3031
-----------------------------------------------------
Fax | 949-495-9238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TA 0681
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12963TPA
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC1430
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------