Provider Demographics
NPI:1477534253
Name:NISHEK, BRIAN SCOTT (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:NISHEK
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 1:324 N HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-8012
Mailing Address - Country:US
Mailing Address - Phone:704-483-2263
Mailing Address - Fax:704-483-6136
Practice Address - Street 1:324 N HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-8012
Practice Address - Country:US
Practice Address - Phone:704-483-2263
Practice Address - Fax:704-483-6136
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1819152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093MVMedicaid
NC093MVOtherBCBS
NCU94481Medicare UPIN
NC89093MVMedicaid