Provider Demographics
NPI:1710914973
Name:MILES, JERRY KEITH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:KEITH
Last Name:MILES
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 1:17215 RED OAK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2697
Mailing Address - Country:US
Mailing Address - Phone:281-444-4114
Mailing Address - Fax:281-444-7789
Practice Address - Street 1:17215 RED OAK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2697
Practice Address - Country:US
Practice Address - Phone:281-444-4114
Practice Address - Fax:281-444-7789
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1327213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127189202Medicaid
TX80203XOtherBCBS
TX82661NMedicare ID - Type Unspecified
TXU62387Medicare UPIN
TX127189202Medicaid