Provider Demographics
NPI:1306207261
Name:MILLER, LAURA (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2107
Mailing Address - Country:US
Mailing Address - Phone:478-633-1721
Mailing Address - Fax:478-633-2316
Practice Address - Street 1:764 PINE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2107
Practice Address - Country:US
Practice Address - Phone:478-633-1721
Practice Address - Fax:478-633-2316
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA009658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program