Provider Demographics
NPI:1710085709
Name:JONAS, NICOLE RENEE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:JONAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:MIESNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:200 S EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38626600Medicaid
WIP00224977OtherRAILROAD MEDICARE
WI002643050Medicare PIN
WIP00224977OtherRAILROAD MEDICARE