Provider Demographics
NPI:1326225053
Name:WILES, DOUGLAS E
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:WILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 E KARSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3403
Mailing Address - Country:US
Mailing Address - Phone:573-701-9015
Mailing Address - Fax:573-701-0103
Practice Address - Street 1:1032 E KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3403
Practice Address - Country:US
Practice Address - Phone:573-701-9015
Practice Address - Fax:573-701-0103
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008-0010237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8215212OtherBC/BS OF IL