MEDICARE: TAMARA NICHOLAS LDO

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	156FX1800X	Optician	DO7121	FL

General Provider Information

NPI Number	:	1235821026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA NICHOLAS LDO

Provider Business Mailing Address
First Line	:	5565 20TH ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4632
Country	:	US
Telephone Number	:	772-978-0722
Fax Number	:	772-978-7786

Provider Business Practice Location Address
First Line	:	5565 20TH ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4632
Country	:	US
Telephone Number	:	772-978-0722
Fax Number	:	772-978-7786

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

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/22/2023

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Directions to “ TAMARA NICHOLAS LDO” Practice Location

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