Provider Demographics
NPI:1114912789
Name:WORONICK, MICHAEL T (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:WORONICK
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 1:277 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6934
Mailing Address - Country:US
Mailing Address - Phone:203-748-7393
Mailing Address - Fax:203-743-2825
Practice Address - Street 1:277 WHITE ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6934
Practice Address - Country:US
Practice Address - Phone:203-748-7393
Practice Address - Fax:203-743-2825
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2008-10-01
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
CT001032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004062048Medicaid
CT410000360Medicare PIN
CTT23350Medicare UPIN
CT0141890001Medicare NSC