Healthcare Provider Details

I. General information

NPI: 1982825568
Provider Name (Legal Business Name): DIANA C MILLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE M5
SANTA FE NM
87505-2106
US

IV. Provider business mailing address

11 N RANCHO DE BOSQUE
LAMY NM
87540-7573
US

V. Phone/Fax

Practice location:
  • Phone: 760-238-3158
  • Fax:
Mailing address:
  • Phone: 760-238-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2015-0419
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: