Provider Demographics
NPI:1114540762
Name:TAKITA, NICOLE ELISE (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELISE
Last Name:TAKITA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELISE
Other - Last Name:GRUZIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:174 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:PA
Mailing Address - Zip Code:18917-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:174 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:PA
Practice Address - Zip Code:18917-2001
Practice Address - Country:US
Practice Address - Phone:215-249-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist