Basic Information
| Provider Information | |||||||||
| NPI: | 1194723809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10370 PARK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045428253 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10370 PARK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045428253 | ||||||||
| FaxNumber: | 7045410186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 143 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0103X | 143 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8908123 | 05 | NC | MEDICAID |