Provider Demographics
NPI:1184903536
Name:ROSS, NICOLE CHRISTIE (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:CHRISTIE
Last Name:ROSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WOODVIEW WAY
Mailing Address - Street 2:APT 214
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-869-4317
Mailing Address - Fax:
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1220
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:617-236-6323
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2297152W00000X
MA5047152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055783800Medicaid
MA110100998AMedicaid
MA110100998AMedicaid
MD242709ZAM2Medicare PIN