Provider Demographics
NPI:1689638405
Name:CANDELA, PETER V (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:V
Last Name:CANDELA
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 1:4110 MOSEBY ST
Mailing Address - Street 2:MAIN EXCHANGE PX
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-6118
Mailing Address - Country:US
Mailing Address - Phone:803-790-1849
Mailing Address - Fax:803-790-1846
Practice Address - Street 1:1518 PICKENS ST STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3449
Practice Address - Country:US
Practice Address - Phone:803-306-6121
Practice Address - Fax:803-306-6122
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD07957Medicaid
SCU408476690Medicare PIN
SCU40847Medicare UPIN
SCD07957Medicaid
SCU408476691Medicare PIN