MEDICARE: MILES COLEMAN WALLER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	45921	OK

General Provider Information

NPI Number	:	1750057949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILES COLEMAN WALLER MD

Provider Business Mailing Address
First Line	:	5800 N ROSS AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-7016
Country	:	US
Telephone Number	:	918-671-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2226 E 38TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-3406
Country	:	US
Telephone Number	:	918-671-6400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2021
Last Update Date	:	06/11/2025

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