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General NPI Number Information
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NPI Number | 1770549701
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Entity Type | Individual
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Provider Name | MYLES SIDNEY JERDAN MEDICAL DOCTOR
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 08/28/2020
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Provider Practice Location Address
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Address Line | 1605 WHITESVILLE ST
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City | LAGRANGE
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State | GA
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Zip | 30240-5903
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Country | US
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Telephone | 877-231-3376
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Fax | 850-522-8354
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Provider Business Mailing Address
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Address Line | 2505 HARRISON AVE
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City | PANAMA CITY
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State | FL
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Zip | 32405-4464
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Country | US
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Telephone | 850-233-3376
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Fax | 850-522-8354
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 60136
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | D30796
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number | 030796
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 30796
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License Number State | GA
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