Provider Demographics
NPI:1689779514
Name:MIFFLETON, GEORGE S (OD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:S
Last Name:MIFFLETON
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:6300 E INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6944
Practice Address - Country:US
Practice Address - Phone:704-535-0925
Practice Address - Fax:704-537-0924
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909614Medicaid
NC5066330001Medicare NSC
NCT64604Medicare UPIN
NC8909614Medicaid