Provider Demographics
NPI:1447244637
Name:KOFOS, NICHOLAS MATTHEW (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MATTHEW
Last Name:KOFOS
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 1:180 BOLTON ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3934
Mailing Address - Country:US
Mailing Address - Phone:508-485-0736
Mailing Address - Fax:508-481-7532
Practice Address - Street 1:180 BOLTON ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3934
Practice Address - Country:US
Practice Address - Phone:508-485-0736
Practice Address - Fax:508-481-7532
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA772575OtherTUFTS
MA0392227Medicaid
MAU47255OtherHARVARD PILGRIM
MAW15958Medicare ID - Type Unspecified
MAU47255OtherHARVARD PILGRIM