1760677744 NPI number — D S MILES D P M P A

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760677744 NPI number — D S MILES D P M P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D S MILES D P M P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760677744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PALATKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32131-0368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-328-7228
Provider Business Mailing Address Fax Number:
386-328-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 ZEAGLER DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32177-3860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-328-7228
Provider Business Practice Location Address Fax Number:
386-328-3351
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILES
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
SHEPHERD
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
386-328-7228

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PO2627 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114470600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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