Provider Demographics
NPI:1275689762
Name:PAUL J MISKE PH D LLC
Entity Type:Organization
Organization Name:PAUL J MISKE PH D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MISKE
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:239-242-0588
Mailing Address - Street 1:2045 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-3284
Mailing Address - Country:US
Mailing Address - Phone:239-242-0588
Mailing Address - Fax:239-242-9945
Practice Address - Street 1:916 EL DORADO PKWY W
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-7251
Practice Address - Country:US
Practice Address - Phone:239-242-0588
Practice Address - Fax:239-242-9945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6267103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC54611OtherBCBC OF FL PROVIDER NUMBE
DC54611OtherBCBC OF FL PROVIDER NUMBE
FLK7156Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER