Provider Demographics
NPI:1376513366
Name:MICCA, PETER JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:MICCA
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 1:2100 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2616
Mailing Address - Country:US
Mailing Address - Phone:585-244-6011
Mailing Address - Fax:585-244-0236
Practice Address - Street 1:2100 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2616
Practice Address - Country:US
Practice Address - Phone:585-244-6011
Practice Address - Fax:585-244-0236
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004870152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP011004870OtherBCBS
NYP011004870OtherBCBS
NYRA1533Medicare ID - Type Unspecified
NYJ400002090Medicare PIN