Provider Demographics
NPI:1205022415
Name:MILES V STANICH, MD INC
Entity Type:Organization
Organization Name:MILES V STANICH, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:V
Authorized Official - Last Name:STANICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-733-0360
Mailing Address - Street 1:4460 POINT LOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3925
Mailing Address - Country:US
Mailing Address - Phone:619-733-0360
Mailing Address - Fax:
Practice Address - Street 1:3795 30TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3631
Practice Address - Country:US
Practice Address - Phone:619-260-1958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG24707Medicare PIN