Provider Demographics
NPI:1316900848
Name:MILLER, KWON T (DO)
Entity type:Individual
Prefix:DR
First Name:KWON
Middle Name:T
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636988
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6988
Mailing Address - Country:US
Mailing Address - Phone:888-940-2722
Mailing Address - Fax:513-632-8898
Practice Address - Street 1:715 E WESTERN RESERVE RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-3358
Practice Address - Country:US
Practice Address - Phone:330-726-3204
Practice Address - Fax:330-729-9316
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012150207RC0000X
OH34009913207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3074766Medicaid
OH4303762OtherMEDICARE PTAN
PA001947190Medicaid
PA0019616090004Medicaid
PA0019616090004Medicaid
PA065420Medicare ID - Type Unspecified