Healthcare Provider Details

I. General information

NPI: 1174834659
Provider Name (Legal Business Name): JEFFERSON T. MILEY, M.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12180 N MOPAC EXPY STE B
AUSTIN TX
78758-2909
US

IV. Provider business mailing address

12180 N MOPAC EXPY STE B
AUSTIN TX
78758-2909
US

V. Phone/Fax

Practice location:
  • Phone: 512-617-6767
  • Fax: 512-617-5598
Mailing address:
  • Phone: 512-617-6767
  • Fax: 512-617-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberN5870
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberN5870
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number103329
License Number StateMN

VIII. Authorized Official

Name: JEFFERSON THAYER MILEY
Title or Position: OWNER
Credential: M.D.
Phone: 512-617-6767