Healthcare Provider Details

I. General information

NPI: 1538195243
Provider Name (Legal Business Name): MILES WARREN WHITAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 DOCTORS DR
SANFORD NC
27330-5057
US

IV. Provider business mailing address

1816 DOCTORS DR
SANFORD NC
27330-5057
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-2284
  • Fax: 910-484-1673
Mailing address:
  • Phone: 919-774-8631
  • Fax: 919-718-0784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number36452
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: