Provider Demographics
NPI:1811928013
Name:JOHNSON, MILES MCHANEY (MD)
Entity type:Individual
Prefix:DR
First Name:MILES
Middle Name:MCHANEY
Last Name:JOHNSON
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:PO BOX 9450
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0025
Mailing Address - Country:US
Mailing Address - Phone:479-251-8055
Mailing Address - Fax:479-251-1511
Practice Address - Street 1:2820 E MILLENNIUM PL
Practice Address - Street 2:SUITE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6514
Practice Address - Country:US
Practice Address - Phone:479-251-8055
Practice Address - Fax:479-251-1511
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0060174400000X
ARE0060204R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation