Provider Demographics
NPI:1619180411
Name:MILLER, CARLY J (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARLY
Other - Middle Name:J
Other - Last Name:WOODMANSEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:1865 LIME ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4744
Practice Address - Country:US
Practice Address - Phone:904-321-8400
Practice Address - Fax:904-321-8401
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1030672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006042200Medicaid
FL74264OtherBCBS
FL006042200Medicaid