Provider Demographics
NPI:1154390730
Name:MILLER, MICHAEL LEE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 CHANAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539
Mailing Address - Country:US
Mailing Address - Phone:850-682-2596
Mailing Address - Fax:
Practice Address - Street 1:11 RACETRACK RD NE
Practice Address - Street 2:SUITE E4
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1882
Practice Address - Country:US
Practice Address - Phone:850-200-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0234332086S0129X
FLME984272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD000Medicare UPIN