Provider Demographics
NPI:1316937097
Name:MILLER, LAURENCE IRWIN (DO)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:IRWIN
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 1:506 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2437
Mailing Address - Country:US
Mailing Address - Phone:660-665-1223
Mailing Address - Fax:660-665-2566
Practice Address - Street 1:506 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2437
Practice Address - Country:US
Practice Address - Phone:660-665-1223
Practice Address - Fax:660-665-2566
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33564207W00000X
IA02394207W00000X
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36470OtherBC/BS
IA0945857Medicaid
MO13028OtherBC/BS
IA0945857Medicaid
MO13028OtherBC/BS