Provider Demographics
NPI:1881855211
Name:NICOLE D BOSAK OD INC
Entity Type:Organization
Organization Name:NICOLE D BOSAK OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:BOSAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-444-1149
Mailing Address - Street 1:4842 SPRING VALLEY DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-1012
Mailing Address - Country:US
Mailing Address - Phone:724-444-1149
Mailing Address - Fax:
Practice Address - Street 1:4960 WILLIAM FLYNN HWY
Practice Address - Street 2:SUITE 13
Practice Address - City:ALLISON PARK
Practice Address - State:PA
Practice Address - Zip Code:15101-2354
Practice Address - Country:US
Practice Address - Phone:724-444-1149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000498332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA139263Medicare PIN