Provider Demographics
NPI:1699720870
Name:MILLER, RICHARD A (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1737
Mailing Address - Country:US
Mailing Address - Phone:906-932-3005
Mailing Address - Fax:906-932-3188
Practice Address - Street 1:240 ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1737
Practice Address - Country:US
Practice Address - Phone:906-932-3005
Practice Address - Fax:906-932-3188
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5330000179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38563800Medicaid
MI4104809Medicaid
MI900B765010OtherBLUE CROSS BLUE SHIELD
MI1255620001Medicare NSC
MI4104809Medicaid