Provider Demographics
NPI:1619318367
Name:WOLANIN, BRIAN HENRY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HENRY
Last Name:WOLANIN
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 1:323 FAIRFIELD AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4295
Mailing Address - Country:US
Mailing Address - Phone:614-381-1331
Mailing Address - Fax:
Practice Address - Street 1:5065 MAIN ST # 1140
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4204
Practice Address - Country:US
Practice Address - Phone:203-374-3211
Practice Address - Fax:203-374-9344
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1773152W00000X
CT2904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist