MEDICARE: NICOLE F KOBA 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	DA1177	MD
2	152W00000X	Optometrist	7621000632	DC

General Provider Information

NPI Number	:	1558461012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE F KOBA OD

Provider Business Mailing Address
First Line	:	2100 PENNSYLVANIA AVE NW
Second Line	:	4TH FLOOR
City	:	WASHINGTON
State	:	DC
Zip	:	20037-3202
Country	:	US
Telephone Number	:	202-872-7247
Fax Number	:	202-872-7296

Provider Business Practice Location Address
First Line	:	2100 PENNSYLVANIA AVE NW
Second Line	:	4TH FLOOR
City	:	WASHINGTON
State	:	DC
Zip	:	20037-3202
Country	:	US
Telephone Number	:	202-529-5200
Fax Number	:	202-269-3462

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	06/02/2021

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