Provider Demographics
NPI:1053442798
Name:CHRISTIE, NICHOLAS C (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:C
Last Name:CHRISTIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958 MORAGA RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4525
Mailing Address - Country:US
Mailing Address - Phone:925-283-5350
Mailing Address - Fax:925-283-3881
Practice Address - Street 1:958 MORAGA RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4525
Practice Address - Country:US
Practice Address - Phone:925-283-5350
Practice Address - Fax:925-283-3881
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5253TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052530Medicare PIN
CAT09919Medicare UPIN