Healthcare Provider Details

I. General information

NPI: 1184903536
Provider Name (Legal Business Name): NICOLE CHRISTIE ROSS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 COMMONWEALTH AVE SUITE 2A
BOSTON MA
02215-1220
US

IV. Provider business mailing address

200 WOODVIEW WAY APT 214
WATERTOWN MA
02472
US

V. Phone/Fax

Practice location:
  • Phone: 617-262-2020
  • Fax: 617-236-6323
Mailing address:
  • Phone: 617-869-4317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2297
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number5047
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: