Provider Demographics
NPI:1992701494
Name:KOSHUTA, NICHOLAS LEO (OD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:LEO
Last Name:KOSHUTA
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 1:2820 N GLASSFORD HILL RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2256
Mailing Address - Country:US
Mailing Address - Phone:928-775-5606
Mailing Address - Fax:928-772-4999
Practice Address - Street 1:2820 N GLASSFORD HILL RD
Practice Address - Street 2:STE 101
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2256
Practice Address - Country:US
Practice Address - Phone:928-775-5606
Practice Address - Fax:928-772-4999
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU93455Medicare UPIN
AZ8HBE78Medicare ID - Type Unspecified