Provider Demographics
NPI:1376750786
Name:NIERENDORF, ERICA A (OD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:A
Last Name:NIERENDORF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:N
Other - Last Name:PETITTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:380 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3690
Mailing Address - Country:US
Mailing Address - Phone:860-409-4565
Mailing Address - Fax:860-409-4566
Practice Address - Street 1:72 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4216
Practice Address - Country:US
Practice Address - Phone:860-314-2949
Practice Address - Fax:860-314-2951
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT965152W00000X
CT0965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410000471Medicare PIN
CTT23352Medicare UPIN