Provider Demographics
NPI:1134303258
Name:NIZIOL, MICHAEL STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STANLEY
Last Name:NIZIOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-0669
Mailing Address - Country:US
Mailing Address - Phone:607-844-8201
Mailing Address - Fax:607-231-4216
Practice Address - Street 1:83 LEWIS STREET
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053
Practice Address - Country:US
Practice Address - Phone:607-844-8201
Practice Address - Fax:607-231-4216
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00903851Medicaid
NY696697OtherMVP
NY000910707001OtherHEALTH NOW
NY4226076OtherAETNA
NY040426016556OtherFIDELIS
NY00903851Medicaid