Provider Demographics
NPI:1417083577
Name:MARCONI, NICHOLAS PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:PAUL
Last Name:MARCONI
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 1:166 SYCAMORE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8217
Mailing Address - Country:US
Mailing Address - Phone:802-872-7447
Mailing Address - Fax:802-872-7448
Practice Address - Street 1:166 SYCAMORE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8217
Practice Address - Country:US
Practice Address - Phone:802-872-7447
Practice Address - Fax:802-872-7448
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000260152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT502217OtherARBO OE NUMBER
VT030-0000260OtherLICENSE NUMBER
VTVT0260OtherEYEMED PROVIDER ID NUMBER
VN1274Medicare ID - Type Unspecified
VT502217OtherARBO OE NUMBER
VT127402Medicare PIN