Provider Demographics
NPI:1871640532
Name:NOLAN, TIMOTHY RAY (LIC OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RAY
Last Name:NOLAN
Suffix:
Gender:M
Credentials:LIC OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-1659
Mailing Address - Country:US
Mailing Address - Phone:386-423-2239
Mailing Address - Fax:386-427-8586
Practice Address - Street 1:600 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1659
Practice Address - Country:US
Practice Address - Phone:386-423-2239
Practice Address - Fax:386-427-8586
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2275156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0678420001Medicare NSC