Basic Information
| Provider Information | |||||||||
| NPI: | 1174696595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | EARL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013005777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1056 E RAINES RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013005777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD17219 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 17217 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.