Healthcare Provider Details

I. General information

NPI: 1649279282
Provider Name (Legal Business Name): WAYNE B MILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E WOODHURST DR K-300
SPRINGFIELD MO
65804-4257
US

IV. Provider business mailing address

1200 E WOODHURST DR K-300
SPRINGFIELD MO
65804-4257
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-1188
  • Fax: 417-887-1837
Mailing address:
  • Phone: 417-887-1188
  • Fax: 417-887-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR5876
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: