Provider Demographics
NPI:1619975190
Name:MILES, J. ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:J. ROBERT
Middle Name:
Last Name:MILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 DORT ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4318
Mailing Address - Country:US
Mailing Address - Phone:813-752-3174
Mailing Address - Fax:813-659-3958
Practice Address - Street 1:402 DORT ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4318
Practice Address - Country:US
Practice Address - Phone:813-752-3174
Practice Address - Fax:813-659-3958
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL592344222173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054796400Medicaid
FL30570Medicare ID - Type Unspecified
FL054796400Medicaid