Provider Demographics
NPI:1760155980
Name:MILLER, PETER NICHOLAS (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:NICHOLAS
Last Name:MILLER
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 1:2038 LAKE MURRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-0972
Mailing Address - Country:US
Mailing Address - Phone:561-596-4708
Mailing Address - Fax:
Practice Address - Street 1:3618 SUNSET BLVD STE A
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3046
Practice Address - Country:US
Practice Address - Phone:803-732-4099
Practice Address - Fax:803-227-8992
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD22893Medicaid