Basic Information
| Provider Information | |||||||||
| NPI: | 1528558343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SIMONE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N STATE STREET | ||||||||
| Address2: | GNH 1011 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234097053 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871311352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2018 | ||||||||
| LastUpdateDate: | 07/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 166858 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | MD2022-0567 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 166858 | 05 | CA | MEDICAID |