Provider Demographics
NPI:1437103488
Name:MILLER, GARY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 TOWNE LAKE PKWY
Mailing Address - Street 2:BLDG 200 STE 110
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189
Mailing Address - Country:US
Mailing Address - Phone:770-591-9190
Mailing Address - Fax:770-591-9196
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BLDG 200 STE 110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:770-591-9190
Practice Address - Fax:770-591-9196
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0248442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00265559FMedicaid