Provider Demographics
NPI:1376647396
Name:VASTIS, NICKOLAS ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:ANDREW
Last Name:VASTIS
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 1:627 CRESTMONT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7027
Mailing Address - Country:US
Mailing Address - Phone:803-699-5110
Mailing Address - Fax:
Practice Address - Street 1:350 HARBISON BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2248
Practice Address - Country:US
Practice Address - Phone:803-749-6878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist