Provider Demographics
NPI:1407039050
Name:NICHOLAS J. VIVIANO, MD, LLC
Entity Type:Organization
Organization Name:NICHOLAS J. VIVIANO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VIVIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-893-9464
Mailing Address - Street 1:PO BOX 1259
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1259
Mailing Address - Country:US
Mailing Address - Phone:985-893-9464
Mailing Address - Fax:985-893-9465
Practice Address - Street 1:7031 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4955
Practice Address - Country:US
Practice Address - Phone:985-893-9464
Practice Address - Fax:985-893-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015859207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty