1982786216 NPI number — MR. THOMAS R MILLER JR. OD

Table of content: MR. THOMAS R MILLER JR. OD (NPI 1982786216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982786216 NPI number — MR. THOMAS R MILLER JR. OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
THOMAS
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982786216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11724 RETAIL DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-562-5559
Provider Business Mailing Address Fax Number:
919-562-5563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11724 RETAIL DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-562-5559
Provider Business Practice Location Address Fax Number:
919-562-5563
Provider Enumeration Date:
10/19/2006

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: 152W00000X , with the licence number:  1802 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0929Y . This is a "NC HEALTHCHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0929Y . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890929Y , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2238815 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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