Provider Demographics
NPI:1396777462
Name:MILLER, CALVIN L (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:L
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 1:225 MIDWAY MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1680
Mailing Address - Country:US
Mailing Address - Phone:423-722-0360
Mailing Address - Fax:423-793-1339
Practice Address - Street 1:110 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4004
Practice Address - Country:US
Practice Address - Phone:423-722-0360
Practice Address - Fax:423-793-1339
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000016717207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396777462Medicaid
TN3332479Medicaid
B05781Medicare UPIN
TN3332479Medicaid
TN0284010002Medicare NSC