Provider Demographics
NPI:1861586562
Name:MOTTO, NICHOLAS (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MOTTO
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:29 BUCKLAND ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1601
Practice Address - Country:US
Practice Address - Phone:860-646-6655
Practice Address - Fax:860-647-7872
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2598152W00000X, 152W00000X
GA002037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFXZMedicare ID - Type Unspecified
GAU97444Medicare UPIN