Healthcare Provider Details

I. General information

NPI: 1992766646
Provider Name (Legal Business Name): JOHN J. MIELKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S CHEVY CHASE DR SUITE 103
GLENDALE CA
91205-4431
US

IV. Provider business mailing address

PO BOX 127
NAPA CA
94559-0127
US

V. Phone/Fax

Practice location:
  • Phone: 818-265-2246
  • Fax:
Mailing address:
  • Phone: 707-255-3300
  • Fax: 707-255-3527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: