Provider Demographics
NPI:1649279282
Name:MILES, WAYNE B (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:B
Last Name:MILES
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 1:1200 E WOODHURST DR
Mailing Address - Street 2:K-300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4257
Mailing Address - Country:US
Mailing Address - Phone:417-887-1188
Mailing Address - Fax:417-887-1837
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:K-300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4257
Practice Address - Country:US
Practice Address - Phone:417-887-1188
Practice Address - Fax:417-887-1837
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5876174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO667282OtherUNITED HEALTHCARE
MO20479OtherBLUE CROSS BLUE SHIELD
MO000004270Medicare ID - Type Unspecified
MOA11072Medicare UPIN