Provider Demographics
NPI:1518309277
Name:ASHLEY, MILES DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:DAVID
Last Name:ASHLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3710
Mailing Address - Country:US
Mailing Address - Phone:601-636-6364
Mailing Address - Fax:601-636-1162
Practice Address - Street 1:1808 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3710
Practice Address - Country:US
Practice Address - Phone:601-636-6364
Practice Address - Fax:601-636-1162
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS878OtherMS STATE LICENSE
MS09001077Medicaid
MS09001077Medicaid