MEDICARE: NICOLE A REGIS O.D.

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	152W00000X	Optometrist	TA2322	MD

General Provider Information

NPI Number	:	1487090114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE A REGIS O.D.

Provider Business Mailing Address
First Line	:	2023 PULASKI HWY
Second Line	:
City	:	HAVRE DE GRACE
State	:	MD
Zip	:	21078-2137
Country	:	US
Telephone Number	:	410-939-6477
Fax Number	:	410-939-6555

Provider Business Practice Location Address
First Line	:	127 LUBRANO DR STE 301
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-7560
Country	:	US
Telephone Number	:	410-224-2010
Fax Number	:	410-224-3044

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

Provider Enumeration Date	:	05/21/2013
Last Update Date	:	07/21/2022

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Directions to “ NICOLE A REGIS O.D.” Practice Location

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