Provider Demographics
NPI:1548577471
Name:SOPP, NICOLE M (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SOPP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:PSALTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1412
Mailing Address - Street 2:
Mailing Address - City:SOUTH DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02660-1412
Mailing Address - Country:US
Mailing Address - Phone:150-839-4221
Mailing Address - Fax:508-398-4471
Practice Address - Street 1:38 ROUTE 134
Practice Address - Street 2:
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660-3700
Practice Address - Country:US
Practice Address - Phone:150-839-4221
Practice Address - Fax:508-398-4471
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD16089Medicaid
SCAA67522326OtherMEDICARE PTAN
MAS400176567OtherMEDICARE PTAN