Provider Demographics
NPI:1689880395
Name:NICKOLA, PAUL F (OD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:F
Last Name:NICKOLA
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 1:1710 LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625
Mailing Address - Country:US
Mailing Address - Phone:989-588-6103
Mailing Address - Fax:
Practice Address - Street 1:675 E BIG BEAVER
Practice Address - Street 2:SUITE 211 SENIOR VISION CARE
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-619-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist