Provider Demographics
NPI:1992880751
Name:MILLER, GORDON ALLAN (DPM)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:ALLAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 HAMPTON CTR
Mailing Address - Street 2:STE B
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1704
Mailing Address - Country:US
Mailing Address - Phone:304-599-9000
Mailing Address - Fax:304-599-4091
Practice Address - Street 1:2000 HAMPTON CTR
Practice Address - Street 2:#B
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1704
Practice Address - Country:US
Practice Address - Phone:304-599-9000
Practice Address - Fax:304-599-4091
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0244213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720161OtherBC/BS
WV0099645000Medicaid
WVU28183Medicare UPIN
WVMI0698501Medicare PIN