Healthcare Provider Details

I. General information

NPI: 1902894579
Provider Name (Legal Business Name): DANIELA NICOSIA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 04/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7071 N 138TH AVE
LUKE AFB AZ
85307
US

IV. Provider business mailing address

6501 E GREENWAY PKWY STE 103-148
SCOTTSDALE AZ
85254-2065
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-0332
  • Fax: 623-536-0332
Mailing address:
  • Phone: 602-469-1834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1030
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: