Basic Information
| Provider Information | |||||||||
| NPI: | 1124098140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | CHANDRA | ||||||||
| MiddleName: | MAREA | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 4019 EXECUTIVE DRIVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305663433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705336500 | ||||||||
| FaxNumber: | 7705336543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 054012 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2380879 | 01 | GA | CIGNA | OTHER | 302583 | 01 | GA | WELLCARE | OTHER | 7747589 | 01 | GA | AETNA | OTHER | 716964757B | 05 | GA | MEDICAID | 716964757C | 05 | GA | MEDICAID | 531457 | 01 | GA | WELLCARE | OTHER | 716964757D | 05 | GA | MEDICAID | 716964757E | 05 | GA | MEDICAID | 52887375 | 01 | GA | BCBS | OTHER | 1201908 | 01 | GA | UNITED HEALTHCARE | OTHER | 302584 | 01 | GA | WELLCARE | OTHER | 716964757A | 05 | GA | MEDICAID | 302582 | 01 | GA | WELLCARE | OTHER | 302585 | 01 | GA | WELLCARE | OTHER | 10033004 | 01 | GA | AMERIGROUP | OTHER |