Provider Demographics
NPI:1487613543
Name:MILLER, THEODORE MARSHALL (OD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:MARSHALL
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:KAPAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96755-0053
Mailing Address - Country:US
Mailing Address - Phone:808-889-0044
Mailing Address - Fax:808-884-5134
Practice Address - Street 1:54 3886 AKONI PULE HWY
Practice Address - Street 2:SUITE #5
Practice Address - City:KAPAAU
Practice Address - State:HI
Practice Address - Zip Code:96755-0053
Practice Address - Country:US
Practice Address - Phone:808-889-0044
Practice Address - Fax:808-884-5134
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIC28013OtherHMSA HEALTH INSURANCE
0000PGBGVMedicare ID - Type Unspecified
T41219Medicare UPIN