Provider Demographics
NPI:1407219124
Name:MILES, KRYSTLE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE STE 1924
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3616
Mailing Address - Country:US
Mailing Address - Phone:312-572-9608
Mailing Address - Fax:
Practice Address - Street 1:14 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2606
Practice Address - Country:US
Practice Address - Phone:708-383-0113
Practice Address - Fax:708-383-9911
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208600000X208600000X
MO2018016173208D00000X
IL125-074854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice