Provider Demographics
NPI:1669486148
Name:MILLER, LISA ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:BLEEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1329 WEST 96TH STREE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-660-0888
Mailing Address - Fax:317-660-0880
Practice Address - Street 1:1329 WEST 96TH STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-660-0888
Practice Address - Fax:317-660-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036098A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000313363OtherANTHEM
IN100121680Medicaid
IN000000313363OtherANTHEM
INE06489Medicare UPIN
IN100121680Medicaid
INP00105409Medicare PIN