Provider Demographics
NPI:1043282262
Name:MILLER, GREGORY LEE (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 N GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4601
Mailing Address - Country:US
Mailing Address - Phone:209-823-7146
Mailing Address - Fax:209-823-0670
Practice Address - Street 1:138 N GRANT AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4601
Practice Address - Country:US
Practice Address - Phone:209-823-7146
Practice Address - Fax:209-823-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05909T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059090Medicaid
CA45547OtherSAFEGUARD
CASD0059090OtherMEDICARE PTAN
CA3417OtherMESC
CA3417OtherMESC
CASD0059090OtherMEDICARE PTAN