Provider Demographics
NPI:1174572903
Name:MILLER, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W RALPH HALL PKWY STE 221
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6662
Mailing Address - Country:US
Mailing Address - Phone:972-772-5450
Mailing Address - Fax:972-772-5452
Practice Address - Street 1:1005 W RALPH HALL PKWY STE 221
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6662
Practice Address - Country:US
Practice Address - Phone:972-772-5450
Practice Address - Fax:972-772-5452
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0428831-02Medicaid
TX080175603OtherRR MEDICARE
TX080175603OtherRR MEDICARE
TXH03552Medicare UPIN
TX8503NOMedicare ID - Type Unspecified