Provider Demographics
NPI:1790802841
Name:COLES, MIREILLE ANTONINE (MD)
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:ANTONINE
Last Name:COLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIREILLE
Other - Middle Name:ANTONINE
Other - Last Name:COLES JACOB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2101 NE 26TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305
Mailing Address - Country:US
Mailing Address - Phone:954-564-8542
Mailing Address - Fax:954-564-3364
Practice Address - Street 1:2101 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:954-564-8542
Practice Address - Fax:954-564-3364
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0035833207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
E34391Medicare UPIN
FL93830Medicare ID - Type Unspecified