Provider Demographics
NPI:1720577638
Name:VISALLI, JOSHUA D (OD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:VISALLI
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 1:99 US ROUTE 1 BYP
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1559
Mailing Address - Country:US
Mailing Address - Phone:207-439-0410
Mailing Address - Fax:
Practice Address - Street 1:99 US ROUTE 1 BYP
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1559
Practice Address - Country:US
Practice Address - Phone:207-439-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT1080152W00000X
GA1234152WP0200X
PAOEG003761152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT003095OtherGA LICENSE