Provider Demographics
NPI:1770766214
Name:MILLER, MARK EDWARD I (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:MILLER
Suffix:I
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 S MONTEZUMA ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4787
Mailing Address - Country:US
Mailing Address - Phone:928-776-0321
Mailing Address - Fax:928-776-0014
Practice Address - Street 1:240 S MONTEZUMA ST STE 204
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4787
Practice Address - Country:US
Practice Address - Phone:928-776-0321
Practice Address - Fax:928-776-0014
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ60009Medicare UPIN