Basic Information
| Provider Information | |||||||||
| NPI: | 1043678444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | JAMISON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | SHAWN | ||||||||
| OtherMiddleName: | JAMISON | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1363 ROCKBRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235081339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649061946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579532958 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2016 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101263022 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | SC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 171000000X | Y | Other Service Providers | Military Health Care Provider |
No ID Information.