Basic Information
Provider Information | |||||||||
NPI: | 1376591875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | DONALD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | L-3549 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432600001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403837927 | ||||||||
FaxNumber: | 7403837942 | ||||||||
Practice Location | |||||||||
Address1: | 1050 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | OH | ||||||||
PostalCode: | 433026416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403838063 | ||||||||
FaxNumber: | 7403877019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 11/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35038734M | OH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1600271 | 01 |   | UHC | OTHER | 300029085 | 01 |   | TRAVELERS MEDICARE | OTHER | 311098079 | 01 |   | TAX ID | OTHER | 643273 | 01 |   | AETNA | OTHER | 0639661 | 01 |   | PALMETTO MEDICARE | OTHER | 311098079 | 01 |   | PPO NEXT | OTHER | 353077 | 01 |   | SUBMITTER NO | OTHER | 311098079249 | 01 |   | MEDICAL MUTUAL | OTHER | 0363244 | 05 | OH |   | MEDICAID | 311098079014 | 01 |   | CIGNA | OTHER | 000000323806 | 01 | OH | ANTHEM | OTHER | 31109807913 | 01 | OH | WORKERS COMP | OTHER | 31109807913 | 01 |   | WORKERS COMPENSATION | OTHER |