Provider Demographics
NPI:1801954458
Name:MILLER, LISA DAWN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:DAWN
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 1:4152 BAKER ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1404
Mailing Address - Country:US
Mailing Address - Phone:770-788-1077
Mailing Address - Fax:770-788-0768
Practice Address - Street 1:4152 BAKER ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1404
Practice Address - Country:US
Practice Address - Phone:770-788-1077
Practice Address - Fax:770-788-0768
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00618945DMedicaid
GA00512OtherBCBS
GA00618945EMedicaid