Provider Demographics
NPI:1891790622
Name:VAN VLIET, MILLER J (DO)
Entity Type:Individual
Prefix:
First Name:MILLER
Middle Name:J
Last Name:VAN VLIET
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PROVIDENCE RD
Mailing Address - Street 2:ST. 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1468
Mailing Address - Country:US
Mailing Address - Phone:704-749-5800
Mailing Address - Fax:704-749-5819
Practice Address - Street 1:240 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-8346
Practice Address - Country:US
Practice Address - Phone:704-749-5800
Practice Address - Fax:704-749-5819
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401590207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89138J9Medicaid
NC2035752BOtherMEDICARE PTAN
NC2035752DOtherMEDICARE PTAN
NC2035752DOtherMEDICARE PTAN
2035752Medicare ID - Type Unspecified
NC89138J9Medicaid