Provider Demographics
NPI:1215933973
Name:MILLER, A LARRY (MD)
Entity type:Individual
Prefix:
First Name:A
Middle Name:LARRY
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 1:311 MAPLE AVE W
Mailing Address - Street 2:STE H
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4309
Mailing Address - Country:US
Mailing Address - Phone:703-938-5660
Mailing Address - Fax:703-242-8712
Practice Address - Street 1:311 MAPLE AVE W
Practice Address - Street 2:STE H
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4309
Practice Address - Country:US
Practice Address - Phone:703-938-5660
Practice Address - Fax:703-242-8712
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-09
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
VA0101026494174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101026494OtherMEDICAL LICENCE
207KA0200XOtherTAXONOMY
D09341Medicare UPIN