Basic Information
| Provider Information | |||||||||
| NPI: | 1427465483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708388563 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 QUARTZ DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301803255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708123530 | ||||||||
| FaxNumber: | 7708123531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 076055 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 100012503 | 01 | NY | GHI | OTHER |