Provider Demographics
NPI:1558349738
Name:NIELSEN, CRAIG LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LAWRENCE
Last Name:NIELSEN
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 1:105 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6516
Mailing Address - Country:US
Mailing Address - Phone:203-235-9519
Mailing Address - Fax:203-379-0289
Practice Address - Street 1:105 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6516
Practice Address - Country:US
Practice Address - Phone:203-235-9519
Practice Address - Fax:203-379-0289
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004086650Medicaid
CTT22986Medicare UPIN
CT004086650Medicaid
CTC00543Medicare PIN