Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | D5443 | TX |
NPI | 1225185531 |
---|---|
Provider Name | Dr. John Miller |
First Address | Nacogdoches, TX 75962-0001 |
Second Address | Nacogdoches, TX 75962-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D66986 | (02) | MS |