Healthcare Provider Details

I. General information

NPI: 1144235599
Provider Name (Legal Business Name): TODD NITCHMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 ST ROBERT BLVD
SAINT ROBERT MO
65584-3311
US

IV. Provider business mailing address

21050 ROWDEN LN
WAYNESVILLE MO
65583-2711
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-7407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2001018906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: