Basic Information
| Provider Information | |||||||||
| NPI: | 1982872990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILETIC | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210313521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Practice Location | |||||||||
| Address1: | 5365 ATLANTIC AVE STE 504 | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614956300 | ||||||||
| FaxNumber: | 5614958877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2008 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | ME106247 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0000X | ME106247 | FL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | ME106247 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME106247 | 01 | FL | FL LICENSE | OTHER |