Provider Demographics
NPI:1932240256
Name:SOTO, NICHOLE Q (THERAPEUTIC OPTOMETR)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:Q
Last Name:SOTO
Suffix:
Gender:F
Credentials:THERAPEUTIC OPTOMETR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-2748
Mailing Address - Country:US
Mailing Address - Phone:361-729-2020
Mailing Address - Fax:361-729-4525
Practice Address - Street 1:2740 HWY 35 NORTH
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382
Practice Address - Country:US
Practice Address - Phone:361-729-2020
Practice Address - Fax:361-729-4525
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5951TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143025801Medicaid
0020FBOtherBCBS
0020FBOtherBCBS
TX4476290001Medicare NSC
00194PMedicare ID - Type Unspecified