Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 012863 | MS |
Y | 208600000X | Surgeon | 012863 | MS |
NPI | 1013983675 |
---|---|
Provider Name | John Miller |
First Address | Gulfport, MS 39506-7137 |
Second Address | Biloxi, MS 39531-4536 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2006 |
Last Update Date | 06/01/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00125370 | (05) | MS |
G84101 | (02) | MS |
P00608339 | RAILROAD MEDICARE (01) |