Provider Demographics
NPI:1760614598
Name:NOSACKA, DOUGLAS P (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:P
Last Name:NOSACKA
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 1:1122 N DOUGLASS ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1342
Mailing Address - Country:US
Mailing Address - Phone:573-276-3239
Mailing Address - Fax:
Practice Address - Street 1:1122 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1342
Practice Address - Country:US
Practice Address - Phone:573-276-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011030374152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist