Provider Demographics
NPI:1295754182
Name:MILES, HENRY E (OD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:E
Last Name:MILES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DELTONA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4204
Mailing Address - Country:US
Mailing Address - Phone:904-797-5760
Mailing Address - Fax:904-797-5762
Practice Address - Street 1:25 DELTONA BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4204
Practice Address - Country:US
Practice Address - Phone:904-797-5760
Practice Address - Fax:904-797-5762
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19013-ZOtherMEDICARE ID
FLT84089Medicare UPIN