Provider Demographics
NPI:1679527410
Name:MILLER, ROGER (OD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
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 1:6527 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-4827
Mailing Address - Country:US
Mailing Address - Phone:941-924-5745
Mailing Address - Fax:941-923-7559
Practice Address - Street 1:6527 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-4827
Practice Address - Country:US
Practice Address - Phone:941-924-5745
Practice Address - Fax:941-923-7559
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84156Medicare UPIN
FL19874Medicare ID - Type Unspecified