Healthcare Provider Details

I. General information

NPI: 1407911662
Provider Name (Legal Business Name): SAMUEL I MILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE 425E
LOS ANGELES CA
90048-5908
US

IV. Provider business mailing address

11901 SANTA MONICA BLVD # 532
LOS ANGELES CA
90025-2767
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-1674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG30941
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG30941
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberG30941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: