Provider Demographics
NPI:1417987603
Name:KOSKI, NICOLE POLIDORI (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:POLIDORI
Last Name:KOSKI
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 1:13400 E 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312
Mailing Address - Country:US
Mailing Address - Phone:586-939-1122
Mailing Address - Fax:586-939-9328
Practice Address - Street 1:13400 E 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48312
Practice Address - Country:US
Practice Address - Phone:586-939-1122
Practice Address - Fax:586-939-9328
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI410046052OtherMEDICARE RAILROAD
MI0166710001OtherADMINASTAR FEDERAL
MI0166710001OtherADMINASTAR FEDERAL
U93700Medicare UPIN