Basic Information
| Provider Information | |||||||||
| NPI: | 1477540318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098295311 | ||||||||
| FaxNumber: | 3098278027 | ||||||||
| Practice Location | |||||||||
| Address1: | 2475 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178755900 | ||||||||
| FaxNumber: | 2178755600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046006095 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 103363001 | 01 | DMERC | OTHER | P00104657 | 01 | RAILROAD MEDICARE | OTHER | 05832035 | 01 | BCBS | OTHER |