Provider Demographics
NPI:1720078264
Name:MILLER, THEODORE H (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N GRAND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1765
Mailing Address - Country:US
Mailing Address - Phone:859-781-4900
Mailing Address - Fax:859-572-3039
Practice Address - Street 1:40 NORTH GRAND AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:FT. THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075
Practice Address - Country:US
Practice Address - Phone:859-781-4900
Practice Address - Fax:859-781-3039
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25084207YX0905X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH64250848Medicaid
000000033216OtherANTHEM BC/BS
OH64250848Medicaid
KY1446701Medicare ID - Type Unspecified
KY040001786Medicare ID - Type UnspecifiedRAILROAD