Provider Demographics
NPI:1881663557
Name:MILES, ALEXIS ANN WIESENTHAL (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ANN WIESENTHAL
Last Name:MILES
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:ANN
Other - Last Name:WIESENTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6627
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209
Mailing Address - Country:US
Mailing Address - Phone:210-614-1010
Mailing Address - Fax:210-949-1010
Practice Address - Street 1:333 W OLMOS DR #18
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-614-1010
Practice Address - Fax:210-949-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36165207R00000X
CAA103118207R00000X
TXN1219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219490401Medicaid
TX219490401Medicaid