Basic Information
| Provider Information | |||||||||
| NPI: | 1366505364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | PAYER CREDENTIALING | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287732559 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 S CANDY LN | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286396180 | ||||||||
| FaxNumber: | 9286396698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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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 | 207ZP0102X | 5414499-1205 | UT | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 36457 | AZ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 264578 | 05 | AZ | MEDICAID |