Provider Demographics
NPI:1053405746
Name:MILLER, DYREK EVERETH (MD)
Entity type:Individual
Prefix:
First Name:DYREK
Middle Name:EVERETH
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 490
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349
Mailing Address - Country:US
Mailing Address - Phone:910-275-0027
Mailing Address - Fax:910-296-0214
Practice Address - Street 1:211 DUPLIN STREET
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-2834
Practice Address - Country:US
Practice Address - Phone:910-275-0027
Practice Address - Fax:910-296-0214
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300667208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1334XOtherBCBS OF NORTH CAROLINA
NC891334XMedicaid
H43469Medicare UPIN
NC2016061Medicare ID - Type Unspecified