Provider Demographics
NPI:1144278821
Name:MISTO, HOLLY M (OD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:MISTO
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 1:17 WELLS ST
Mailing Address - Street 2:STE 101
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2923
Mailing Address - Country:US
Mailing Address - Phone:401-348-2020
Mailing Address - Fax:401-596-9348
Practice Address - Street 1:17 WELLS ST
Practice Address - Street 2:STE 101
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2923
Practice Address - Country:US
Practice Address - Phone:401-348-2020
Practice Address - Fax:401-596-9348
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9021231Medicaid
RI007056427Medicare PIN
RI0186990001Medicare NSC
RI9021231Medicaid