Provider Demographics
NPI:1124191333
Name:MILLER, MARK LOUIS (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:8008 WESTPARK DR
Practice Address - Street 2:KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3109
Practice Address - Country:US
Practice Address - Phone:703-287-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000673213ES0103X
MD00610213ES0103X
DCPO361213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
006030M92Medicare ID - Type Unspecified
T30904Medicare UPIN