1093569220 NPI number — DR. DEMETRIA ANN MILLER DO

Table of content: DR. DEMETRIA ANN MILLER DO (NPI 1093569220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093569220 NPI number — DR. DEMETRIA ANN MILLER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
DEMETRIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
XENOS
Provider Other First Name:
DEMETRIA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093569220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
945 ROBIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14228-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-517-1064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 MEDICAL CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAVAZOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-553-9089
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  BP10086846 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)