Provider Demographics
NPI:1710038245
Name:MILLER, ELLEN CAROL (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:CAROL
Last Name:MILLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 NEWCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-4784
Mailing Address - Country:US
Mailing Address - Phone:319-373-3737
Mailing Address - Fax:
Practice Address - Street 1:576 BOYSON RD NE
Practice Address - Street 2:SUITE 104
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-7363
Practice Address - Country:US
Practice Address - Phone:319-373-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3127506Medicaid
U57858Medicare UPIN