Basic Information
| Provider Information | |||||||||
| NPI: | 1760952436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | THADDEUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 749 UNIVERSITY ROW STE 200 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537051465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082636400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 749 UNIVERSITY ROW STE 200 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537051465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082636400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/18/2021 | ||||||||
| NPIReactivationDate: | 04/26/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 9405-851 | WI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.