Provider Demographics
NPI:1285625350
Name:MILLER, PHILLIP M (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2126
Mailing Address - Country:US
Mailing Address - Phone:530-926-7196
Mailing Address - Fax:530-926-1026
Practice Address - Street 1:408 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2126
Practice Address - Country:US
Practice Address - Phone:530-926-7196
Practice Address - Fax:530-926-1026
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G867290Medicaid
CA00G867290Medicaid
CA00G867290Medicare ID - Type Unspecified