Provider Demographics
NPI:1477810851
Name:MILES, AMANDA JO (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:MILES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4139
Mailing Address - Country:US
Mailing Address - Phone:918-225-3006
Mailing Address - Fax:918-225-0894
Practice Address - Street 1:1102 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4139
Practice Address - Country:US
Practice Address - Phone:918-225-3006
Practice Address - Fax:918-225-0894
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29120207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200525990BMedicaid
OK521619YLV0Medicare PIN