Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 12217 | AZ |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 12217 | AZ |
NPI | 1124028220 |
---|---|
Provider Name | Mr. Fred Douglas Miller |
First Address | Phoenix, AZ 85022-3734 |
Second Address | Tucson, AZ 85712-2802 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
263773 | (05) | AZ |
AZ0725850 | BLUE CROSS/BLUE SHIELD (01) | AZ |
D37311 | (02) |