Provider Demographics
NPI:1871543199
Name:MILLER, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
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:PO BOX 28199
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0199
Mailing Address - Country:US
Mailing Address - Phone:858-675-3100
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:211 13TH ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2711
Practice Address - Country:US
Practice Address - Phone:760-789-5160
Practice Address - Fax:760-789-6316
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31770-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871543199Medicaid
CA119340OtherSTATE LICENSE
WI007113215Medicare PIN
WI1001051OtherPHYSICIANS PLUS
WI080179107Medicare PIN
WI1001051OtherPHYSICIANS PLUS
WI3766OtherDEAN HEALTH INSURANCE