Active NPI
Jack Edwin Miller, MD
- Neurology Physician
- Petaluma, CA
National Provider Identifier
1497824627
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Neurology Physician
- License
- G26214
- Practice address
- 765 Baywood Dr
#231
Petaluma, CA 94954 - Phone
- (707) 762-2166
- Fax
- (707) 766-8160
- NPI assigned
- Nov 6, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Neurology Physician | 2084N0400X | G26214 | CA | Primary |
Addresses
Primary practice location
765 Baywood Dr
#231
Petaluma, CA 94954
Mailing address
765 Baywood Dr
#231
Petaluma, CA 94954
Phone (707) 762-2166
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160414002137 | CA | Order and Referring Only - Neurology | 2860790458 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G26214 | CA | MD | Neurology Physician |
| 29214 | CA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1162771200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1497824627",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "765 BAYWOOD DR",
"address_2": "#231",
"city": "PETALUMA",
"state": "CA",
"postal_code": "94954",
"telephone_number": "707-762-2166",
"fax_number": "707-766-8160"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "765 BAYWOOD DR",
"address_2": "#231",
"city": "PETALUMA",
"state": "CA",
"postal_code": "94954",
"telephone_number": "707-762-2166",
"fax_number": "707-766-8160"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MILLER",
"first_name": "JACK",
"middle_name": "EDWIN",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-06",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "2084N0400X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Neurology",
"state": "CA",
"license": "G26214",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Petaluma, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.