Provider Demographics
NPI:1790717189
Name:VINER, NICHOLAS A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:VINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 HAWLEY LN
Mailing Address - Street 2:SUITE 002
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5300
Mailing Address - Country:US
Mailing Address - Phone:203-375-3456
Mailing Address - Fax:203-375-4456
Practice Address - Street 1:160 HAWLEY LN
Practice Address - Street 2:SUITE 002
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-5300
Practice Address - Country:US
Practice Address - Phone:203-375-3456
Practice Address - Fax:203-375-4456
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14383174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001143833Medicaid
CT001143833Medicaid
CT340000173Medicare ID - Type Unspecified