Provider Demographics
NPI:1588662746
Name:MILES, JUDITH LYNN (OD)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:LYNN
Last Name:MILES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:L
Other - Last Name:KREMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:200 S KIRKWOOD RD STE 130
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4335
Mailing Address - Country:US
Mailing Address - Phone:314-394-3045
Mailing Address - Fax:314-394-3049
Practice Address - Street 1:200 S KIRKWOOD RD STE 130
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4335
Practice Address - Country:US
Practice Address - Phone:314-394-3045
Practice Address - Fax:314-394-3049
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1588662746Medicaid
MO000009385Medicare PIN
U51727Medicare UPIN
MO074730050Medicare PIN
MO067820049Medicare PIN