Provider Demographics
NPI:1588693014
Name:MILLER, GARY STEPHEN (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:STEPHEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:6801 NORTHLAKE MALL DR
Mailing Address - Street 2:NORTHLAKE MALL #253
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-0711
Mailing Address - Country:US
Mailing Address - Phone:704-509-4490
Mailing Address - Fax:704-509-4491
Practice Address - Street 1:6801 NORTHLAKE MALL DRIVE
Practice Address - Street 2:NORTHLAKE MALL #253
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-0711
Practice Address - Country:US
Practice Address - Phone:704-509-4490
Practice Address - Fax:704-509-4491
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1307152W00000X
VA1521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC562203995OtherTIN
NC562203995OtherTIN
NC2470179BMedicare ID - Type Unspecified