Provider Demographics
NPI:1063437820
Name:MILLER, MARY IRENE (MD)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:IRENE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:ONE POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488
Mailing Address - Country:US
Mailing Address - Phone:203-262-6900
Mailing Address - Fax:203-262-6045
Practice Address - Street 1:ONE POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-262-6900
Practice Address - Fax:203-262-6045
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT034922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LIP063OtherOXFORD
OR4281OtherHEALTH NET
03492ZOtherCONCTCARE
00134922CT07OtherBLUE CROSS
00134922501OtherFAMILY PLAN
00134922501OtherBLUE CARE
00134922CT07OtherBLUE CROSS