Provider Demographics
NPI:1790344430
Name:DR. OTHA MYLES & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DR. OTHA MYLES & ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-812-1889
Mailing Address - Street 1:9150 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114
Mailing Address - Country:US
Mailing Address - Phone:314-449-9633
Mailing Address - Fax:314-449-9634
Practice Address - Street 1:3915 WATSON RD STE 203
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-833-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty