Provider Demographics
NPI:1952399966
Name:MILES, JEFFREY G (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:G
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 1:3725 W 4100 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5530
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:801-965-3740
Practice Address - Street 1:3725 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5530
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:801-965-3740
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3242701205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G70275Medicare UPIN
005750301Medicare ID - Type Unspecified