Provider Demographics
NPI:1124199864
Name:WISNIEWSKI, NICHOLAS E (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:WISNIEWSKI
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 1:715 MIDDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2236
Mailing Address - Country:US
Mailing Address - Phone:860-531-3852
Mailing Address - Fax:860-468-4235
Practice Address - Street 1:715 MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-2236
Practice Address - Country:US
Practice Address - Phone:860-531-3852
Practice Address - Fax:860-468-4235
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTV12408Medicare UPIN