Provider Demographics
NPI:1407407471
Name:LITHGOW, NICOLE MARIE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LITHGOW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 MENDOCINO AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3540 MENDOCINO AVE STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3639
Practice Address - Country:US
Practice Address - Phone:707-522-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist