Provider Demographics
NPI:1962437285
Name:MILLER, KEITH LYNDON (OD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LYNDON
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7667 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-4153
Mailing Address - Country:US
Mailing Address - Phone:509-427-8259
Mailing Address - Fax:509-427-8268
Practice Address - Street 1:136 NW SECOND STREET
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648
Practice Address - Country:US
Practice Address - Phone:509-427-8259
Practice Address - Fax:509-427-8268
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602829747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8873418Medicaid
WAG8873418Medicare PIN