Provider Demographics
NPI:1275699514
Name:MILLER, JACK W (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 PROFESSIONAL PL
Mailing Address - Street 2:STE 104
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-830-7039
Mailing Address - Fax:770-830-7149
Practice Address - Street 1:100 PROFESSIONAL PL
Practice Address - Street 2:STE 104
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3874
Practice Address - Country:US
Practice Address - Phone:770-830-7039
Practice Address - Fax:770-830-7149
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2015-08-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0445412080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000767709CMedicaid
GA000767709CMedicaid