Provider Demographics
NPI:1477549962
Name:MILLER, LAVERNE L (MD)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:L
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 1:210 KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-9570
Mailing Address - Country:US
Mailing Address - Phone:260-760-0956
Mailing Address - Fax:
Practice Address - Street 1:210 KINGSTON RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-9570
Practice Address - Country:US
Practice Address - Phone:260-760-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035849207QG0300X
OH35045593207QG0300X
SCMD88243207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454235Medicaid
OHC01985Medicare UPIN
IN925380Medicare ID - Type Unspecified
OHMI0488973Medicare ID - Type Unspecified