Provider Demographics
NPI:1205909389
Name:MILLICAN, ROBERT DANCY (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DANCY
Last Name:MILLICAN
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 1:1626 FREDERICA RD
Mailing Address - Street 2:STE 101
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1626 FREDERICA RD
Practice Address - Street 2:STE101
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522
Practice Address - Country:US
Practice Address - Phone:912-634-5711
Practice Address - Fax:912-634-5713
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT1245152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
511G700587OtherMEDICARE PTAN#
GA1278400001Medicare NSC
GAU34513Medicare UPIN
41ZCCJXMedicare ID - Type Unspecified
GA41ZCDRCMedicare ID - Type Unspecified