Provider Demographics
NPI:1225093628
Name:NOSIKE, SAMPSON O (OD)
Entity Type:Individual
Prefix:MR
First Name:SAMPSON
Middle Name:O
Last Name:NOSIKE
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 1:339 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1413
Mailing Address - Country:US
Mailing Address - Phone:617-625-3043
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:# 450
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-4600
Practice Address - Fax:617-636-4866
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0313688Medicaid
MAU76243Medicare UPIN
MA0313688Medicaid