Basic Information
| Provider Information | |||||||||
| NPI: | 1104971407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ABBIE MAE | ||||||||
| MiddleName: | BUCK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | ABBIE MAE | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 110 IRVING ST NW | ||||||||
| Address2: | SUITE 1A-50 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200103017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028772835 | ||||||||
| FaxNumber: | 2028778288 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 GALEN ST SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200204913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028772835 | ||||||||
| FaxNumber: | 2028778288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101238313 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 027428500 | 05 | MD | MEDICAID | 089330300 | 05 | DC | MEDICAID | 1104971407 | 05 | VA | MEDICAID |