Provider Demographics
NPI:1942244793
Name:MIIDLA, INDREK (MD)
Entity Type:Individual
Prefix:
First Name:INDREK
Middle Name:
Last Name:MIIDLA
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 1:983 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-7048
Mailing Address - Country:US
Mailing Address - Phone:954-227-2030
Mailing Address - Fax:954-227-2010
Practice Address - Street 1:983 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-7048
Practice Address - Country:US
Practice Address - Phone:954-227-2030
Practice Address - Fax:954-227-2010
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68380208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378197600Medicaid
FL26957AMedicare PIN
FL378197600Medicaid