Provider Demographics
NPI:1659533222
Name:MILLER, MARIAM IMNADZE (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:IMNADZE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 DIPLOMACY DRIVE
Mailing Address - Street 2:DEPT OF UROLOGY
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-729-4443
Mailing Address - Fax:
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:DEPT OF UROLOGY
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:855-482-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101249208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology