Basic Information
| Provider Information | |||||||||
| NPI: | 1871819078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIERAS | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 25050 SE STARK ST | ||||||||
| Address2: | STE 265 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132005 | ||||||||
| FaxNumber: | 5034133699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E 5094 | CA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | POD.0000736 | CO | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | DP181086 | OR | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 329089YXFB | 01 | CO | MEDICARE | OTHER |