Provider Demographics
NPI:1710983176
Name:HUMPHREY, MILES HUBBARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:HUBBARD
Last Name:HUMPHREY
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 1:238 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4542
Mailing Address - Country:US
Mailing Address - Phone:208-734-4670
Mailing Address - Fax:208-734-4990
Practice Address - Street 1:238 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4542
Practice Address - Country:US
Practice Address - Phone:208-734-4670
Practice Address - Fax:208-734-4990
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3006174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDW094OtherBLUE CROSS OF IDAHO
ID002581400Medicaid
ID000010135113OtherBLUE SHIELD OF IDAHO
ID1139964Medicare ID - Type Unspecified
IDDW094OtherBLUE CROSS OF IDAHO