Provider Demographics
NPI:1366484099
Name:MIELKE, GREG M (MD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:M
Last Name:MIELKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3926 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:260-458-5636
Practice Address - Street 1:1111 LIGHTHOUSE LN
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3824
Practice Address - Country:US
Practice Address - Phone:574-533-0348
Practice Address - Fax:574-533-0277
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034860A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100113720Medicaid
IND94743Medicare UPIN
IN100113720Medicaid