Healthcare Provider Details

I. General information

NPI: 1326225053
Provider Name (Legal Business Name): DOUGLAS E WILES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 E KARSCH BLVD
FARMINGTON MO
63640-3403
US

IV. Provider business mailing address

1032 E KARSCH BLVD
FARMINGTON MO
63640-3403
US

V. Phone/Fax

Practice location:
  • Phone: 573-701-9015
  • Fax: 573-701-0103
Mailing address:
  • Phone: 573-701-9015
  • Fax: 573-701-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2008-0010
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: