Provider Demographics
NPI:1861499964
Name:NUNNINK, JOHANNES CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNES
Middle Name:CHRISTIAN
Last Name:NUNNINK
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:PO BOX 1063
Mailing Address - Street 2:111 COLCHESTER AVE
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1063
Mailing Address - Country:US
Mailing Address - Phone:802-847-5465
Mailing Address - Fax:802-656-5493
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-656-0546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006659207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005418Medicaid
VTB85694Medicare UPIN
VT0005418Medicaid