Provider Demographics
NPI:1386645539
Name:MILLER, DWIGHT LARRY (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:LARRY
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DWIGHT
Other - Middle Name:LARRY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6585 CLARK RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-3500
Mailing Address - Country:US
Mailing Address - Phone:530-877-4465
Mailing Address - Fax:530-877-1034
Practice Address - Street 1:6585 CLARK RD
Practice Address - Street 2:SUITE 440
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-3500
Practice Address - Country:US
Practice Address - Phone:530-877-4465
Practice Address - Fax:530-877-1034
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G206710Medicaid
942232162OtherBLUE CROSS
942232162OtherCIGNA
942232162OtherCIGNA
CA00G206710Medicare ID - Type Unspecified