Healthcare Provider Details

I. General information

NPI: 1033265962
Provider Name (Legal Business Name): MILES EDWARD DRAKE JR., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E MAIN ST SUITE 110
COLUMBUS OH
43215-5369
US

IV. Provider business mailing address

500 E MAIN ST SUITE 110
COLUMBUS OH
43215-5369
US

V. Phone/Fax

Practice location:
  • Phone: 614-265-8809
  • Fax: 614-233-9201
Mailing address:
  • Phone: 614-265-8809
  • Fax: 614-233-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number47457
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: