Healthcare Provider Details

I. General information

NPI: 1790344430
Provider Name (Legal Business Name): DR. OTHA MYLES & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 01/11/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 WATSON RD STE 203
SAINT LOUIS MO
63109-1251
US

IV. Provider business mailing address

9150 PAGE AVE
OVERLAND MO
63114
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-4001
  • Fax:
Mailing address:
  • Phone: 314-449-9633
  • Fax: 314-449-9634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OTHA MYLES
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 443-812-1889