Provider Demographics
NPI:1487373460
Name:MILLER, ERIC
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TILDAN
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1862
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74067-1862
Mailing Address - Country:US
Mailing Address - Phone:918-260-6299
Mailing Address - Fax:
Practice Address - Street 1:11090 N 160 RD
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-9180
Practice Address - Country:US
Practice Address - Phone:918-260-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1841919594Medicaid
OK88-3874303Medicaid