=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760406771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LON MILLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 10/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4120 W SOFT WIND DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85310-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-336-3775
-----------------------------------------------------
Fax | 623-547-7196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4120 W SOFT WIND DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85310-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-336-3775
-----------------------------------------------------
Fax | 623-547-7196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | M6077
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD00030099
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------