Provider Demographics
NPI:1235623372
Name:MILLER, JOHNATHAN CHANCE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:CHANCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7122 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2337
Mailing Address - Country:US
Mailing Address - Phone:314-329-8109
Mailing Address - Fax:314-350-0231
Practice Address - Street 1:7122 NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-2337
Practice Address - Country:US
Practice Address - Phone:314-329-8109
Practice Address - Fax:314-350-0231
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020035594208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA101074OtherGA LICENSE
WV31996OtherWV LICENSE
LA334502OtherLA LICENSE
ARE-15164OtherAR LICENSE
IAMD-50615OtherIA LICENSE
NJ25MA11832200OtherNJ LICENSE
IL36156953OtherIL LICENSE
MS31324OtherMS LICENSE
NY319711OtherNY LICENSE
MTMED-PHYS-LIC-116474OtherMT LICENSE
UT12314722-1205OtherUT LICENSE
NC2024-00059OtherNC LICENSE
MI4301508656OtherMI LICENSE
OK37701OtherOK LICENSE
ALMD.45970OtherAL LICENSE
MA1013323OtherMA LICENSE
MO2020035594OtherMO LICENSE
MN75961OtherMN LICENSE
PAMD474783OtherPA LICENSE
OH35.141126OtherOH LICENSE
FLME165293OtherFL LICENSE
TXU7016OtherTX LICENSE
VA101277587OtherVA LICENSE
AZ70912OtherAZ LICENSE
MDD91957OtherMD LICENSE