Provider Demographics
NPI:1902973191
Name:MILLER, KEITH WAYNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7011 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-6727
Mailing Address - Country:US
Mailing Address - Phone:423-855-4567
Mailing Address - Fax:423-855-7946
Practice Address - Street 1:7011 SHALLOWFORD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6727
Practice Address - Country:US
Practice Address - Phone:423-855-4567
Practice Address - Fax:423-855-7946
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM302213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351334Medicaid
TNT61106Medicare UPIN
TN3351334Medicare ID - Type Unspecified