Provider Demographics
NPI:1083018634
Name:MIELKE, DWIGHT
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:MIELKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 136
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-933-4327
Mailing Address - Fax:
Practice Address - Street 1:6801 DIXIE HWY
Practice Address - Street 2:SUITE 136
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3913
Practice Address - Country:US
Practice Address - Phone:502-933-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist