Provider Demographics
NPI:1598853970
Name:WILES, MICHAEL TODD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TODD
Last Name:WILES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 SHALLOWFORD RD STE 213
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2215
Mailing Address - Country:US
Mailing Address - Phone:423-760-3668
Mailing Address - Fax:423-760-3660
Practice Address - Street 1:5959 SHALLOWFORD RD STE 213
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2215
Practice Address - Country:US
Practice Address - Phone:423-760-3668
Practice Address - Fax:423-760-3660
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001113213E00000X
TN663213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3354304Medicaid