Provider Demographics
NPI:1083670566
Name:MILLER, SHAWN SCARBERRY (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:SCARBERRY
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 E ROSS ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0545
Mailing Address - Country:US
Mailing Address - Phone:539-234-4100
Mailing Address - Fax:539-234-4101
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-4100
Practice Address - Fax:539-234-4101
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1452207Q00000X
OK35863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132969001Medicaid
AR5K620OtherARBCBS
5K620Medicare PIN