Provider Demographics
NPI:1639259252
Name:NISENBAUM, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NISENBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WEST MAIN ST
Mailing Address - Street 2:BLDG 2
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-755-9355
Mailing Address - Fax:203-597-8192
Practice Address - Street 1:1320 WEST MAIN ST
Practice Address - Street 2:BLDG 2
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-755-9355
Practice Address - Fax:203-597-8192
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0434092081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3821999OtherAETNA US HEALTH CARE
P00296425OtherRAILROAD MEDICARE
2771432OtherCIGNA
2V7481OtherHEALTH NET
2525598OtherUNITED HEALTH CARE
CT001434092Medicaid
CT010043409CT01OtherANTHEM BCBS OF CT
P3673144OtherOXFORD
043409OtherCONNECTICARE
CT250000357Medicare ID - Type Unspecified
2525598OtherUNITED HEALTH CARE