Healthcare Provider Details

I. General information

NPI: 1366484099
Provider Name (Legal Business Name): GREG M MIELKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LIGHTHOUSE LN
GOSHEN IN
46526-3824
US

IV. Provider business mailing address

3926 NEW VISION DR
FORT WAYNE IN
46845-1712
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-0348
  • Fax: 574-533-0277
Mailing address:
  • Phone: 260-266-8210
  • Fax: 260-458-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01034860A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: