Basic Information
| Provider Information | |||||||||
| NPI: | 1346236478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ESTEBAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 658 LONGFELLOW ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158966911 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 711 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546159108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152845361 | ||||||||
| FaxNumber: | 7152847166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD23886 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 60159-20 | WI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 10028445 | 05 | WI | MEDICAID | 286634 | 05 | OR | MEDICAID | BM7872078 | 01 | OR | DEA | OTHER |