Provider Demographics
NPI:1164478061
Name:MAHAN, MILES E (MD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:E
Last Name:MAHAN
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 1:6600 VAN AALST BLVD
Mailing Address - Street 2:DEPARTMENT OF WOMEN'S HEALTH AND NEWBORN CARE
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:762-408-2605
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:DEPARTMENT OF WOMEN'S HEALTH AND NEWBORN CARE
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:762-408-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4320207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041911102Medicaid
TX041911102Medicaid