Provider Demographics
NPI:1093120958
Name:LANDRY, MILES (MD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:LANDRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 ALCOA HWY # U-11
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:865-305-9230
Mailing Address - Fax:865-305-8894
Practice Address - Street 1:1924 ALCOA HWY # U-11
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-9230
Practice Address - Fax:865-305-8894
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59494208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty