Provider Demographics
NPI:1578758090
Name:NICOLE MINUTOLO OD PLLC
Entity Type:Organization
Organization Name:NICOLE MINUTOLO OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINUTOLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:845-527-8813
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:51 ORANGE ST.
Mailing Address - City:MARLBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12542-0335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 ORANGE ST.
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NY
Practice Address - Zip Code:12542-0335
Practice Address - Country:US
Practice Address - Phone:845-527-8813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC434E1Medicare PIN