Provider Demographics
NPI:1992766646
Name:MIELKE, JOHN J (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MIELKE
Suffix:
Gender:M
Credentials:OD
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 127
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-0127
Mailing Address - Country:US
Mailing Address - Phone:707-255-3300
Mailing Address - Fax:707-255-3527
Practice Address - Street 1:801 S CHEVY CHASE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4431
Practice Address - Country:US
Practice Address - Phone:818-265-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103773Medicaid
CASD0103773Medicaid