MEDICARE: HOLLY M MISTO OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	ODTA00534	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144278821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY M MISTO OD

Provider Business Mailing Address
First Line	:	17 WELLS ST
Second Line	:	STE 101
City	:	WESTERLY
State	:	RI
Zip	:	02891-2923
Country	:	US
Telephone Number	:	401-348-2020
Fax Number	:	401-596-9348

Provider Business Practice Location Address
First Line	:	17 WELLS ST
Second Line	:	STE 101
City	:	WESTERLY
State	:	RI
Zip	:	02891-2923
Country	:	US
Telephone Number	:	401-348-2020
Fax Number	:	401-596-9348

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	04/24/2012

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Directions to “ HOLLY M MISTO OD” Practice Location

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