Provider Demographics
NPI:1770671778
Name:MILES, WENDELL G
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:G
Last Name:MILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 WISCONSIN AVE
Mailing Address - Street 2:SUITE 1135
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4404
Mailing Address - Country:US
Mailing Address - Phone:301-261-7523
Mailing Address - Fax:410-956-4341
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:SUITE 1135
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-261-7523
Practice Address - Fax:410-956-4341
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052768208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD40379440Medicaid
DC491523Medicare PIN
H83022Medicare UPIN