Provider Demographics
NPI:1235245770
Name:MILLER, MARY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:ROSBORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2528
Mailing Address - Country:US
Mailing Address - Phone:916-854-6666
Mailing Address - Fax:916-854-6864
Practice Address - Street 1:89 DAVIS RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3031
Practice Address - Country:US
Practice Address - Phone:925-254-2008
Practice Address - Fax:925-254-8488
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG26820Medicare UPIN
CA00G757031Medicare ID - Type Unspecified