Provider Demographics
NPI:1104816941
Name:MILLER, MICHAEL S (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0003
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:615-269-3087
Practice Address - Street 1:1610 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1182
Practice Address - Country:US
Practice Address - Phone:770-941-3633
Practice Address - Fax:770-874-8950
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000776213EP1101X, 213E00000X, 213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1756393Medicaid
GA362436212AMedicaid
U61909Medicare UPIN
GA48SCCTPMedicare PIN