Healthcare Provider Details

I. General information

NPI: 1700812716
Provider Name (Legal Business Name): GWENDOLYN MILLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E 12TH ST SUITE 101
AUSTIN TX
78701-1954
US

IV. Provider business mailing address

4616 W HOWARD LN
AUSTIN TX
78728-6300
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-9650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH6438
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberH6438
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: