Provider Demographics
NPI:1548651821
Name:JOHN R. MILES MD PA
Entity type:Organization
Organization Name:JOHN R. MILES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-752-3174
Mailing Address - Street 1:402 N DORT ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4318
Mailing Address - Country:US
Mailing Address - Phone:813-752-3174
Mailing Address - Fax:813-659-3958
Practice Address - Street 1:402 N DORT ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4318
Practice Address - Country:US
Practice Address - Phone:813-752-3174
Practice Address - Fax:813-659-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054796400Medicaid
FL054796400Medicaid