Provider Demographics
NPI:1346327301
Name:PSALTIS, JOHN NICKOLAS (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NICKOLAS
Last Name:PSALTIS
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:TROLLEY SQUARE
Mailing Address - Street 2:UNIT 19A
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806
Mailing Address - Country:US
Mailing Address - Phone:302-777-4794
Mailing Address - Fax:302-777-4872
Practice Address - Street 1:3801 KENNETT PIKE STE A102
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:DE
Practice Address - Zip Code:19807-2307
Practice Address - Country:US
Practice Address - Phone:302-777-4794
Practice Address - Fax:302-777-4872
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG000697PA152W00000X
DEI30001211OS152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000553722Medicaid
DEG01011OtherGROUP MEDICARE
DEG01011OtherGROUP MEDICARE
U48794Medicare UPIN