Basic Information
| Provider Information | |||||||||
| NPI: | 1538262407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 CENTRAL PKWY N | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782325085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105369591 | ||||||||
| FaxNumber: | 9044252949 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 S SEGUIN AVE | ||||||||
| Address2: | BLDG E. | ||||||||
| City: | NEW BRAUNFELS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781303914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306267770 | ||||||||
| FaxNumber: | 8552784535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K2246 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | K2246 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | K2246 | 01 | TX | TX LICENSE | OTHER | 353971002 | 05 | TX | MEDICAID |