Healthcare Provider Details

I. General information

NPI: 1710983176
Provider Name (Legal Business Name): MILES HUBBARD HUMPHREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 MARTIN ST
TWIN FALLS ID
83301-4542
US

IV. Provider business mailing address

238 MARTIN ST
TWIN FALLS ID
83301-4542
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-4670
  • Fax: 208-734-4990
Mailing address:
  • Phone: 208-734-4670
  • Fax: 208-734-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM3006
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: