=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861586562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS MOTTO O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 12/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 BUCKLAND ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-6655
-----------------------------------------------------
Fax | 860-647-7872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 OLD GALLOWS RD STE 520
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
Fax | 571-223-6780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2598
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------