Provider Demographics
NPI:1801091129
Name:DESPOTIDIS, NICKY (OD)
Entity type:Individual
Prefix:DR
First Name:NICKY
Middle Name:
Last Name:DESPOTIDIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:DESPOTIDIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 LEONARD DR
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-1664
Mailing Address - Country:US
Mailing Address - Phone:732-972-3275
Mailing Address - Fax:
Practice Address - Street 1:1777 KUSER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON SQUARE
Practice Address - State:NJ
Practice Address - Zip Code:08690-3703
Practice Address - Country:US
Practice Address - Phone:609-581-5755
Practice Address - Fax:609-581-7055
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00469400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ790828BEYMedicare ID - Type Unspecified
NJT77965Medicare UPIN
NJT77695Medicare UPIN
NJ790828BEYMedicare PIN