MEDICARE: NICHOLAS LEO KOSHUTA 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	1264	AZ

General Provider Information

NPI Number	:	1992701494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS LEO KOSHUTA O.D.

Provider Business Mailing Address
First Line	:	2820 N GLASSFORD HILL RD
Second Line	:	STE 101
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2256
Country	:	US
Telephone Number	:	928-775-5606
Fax Number	:	928-772-4999

Provider Business Practice Location Address
First Line	:	2820 N GLASSFORD HILL RD
Second Line	:	STE 101
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2256
Country	:	US
Telephone Number	:	928-775-5606
Fax Number	:	928-772-4999

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	07/08/2007

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