Provider Demographics
NPI:1720083421
Name:WINICKI, RAYMOND E (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:E
Last Name:WINICKI
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 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2520
Mailing Address - Country:US
Mailing Address - Phone:203-578-4630
Mailing Address - Fax:203-578-4629
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:STE 201
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2520
Practice Address - Country:US
Practice Address - Phone:203-578-4630
Practice Address - Fax:203-578-4629
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040374207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001403740Medicaid
CTG88879Medicare UPIN
CTD400019511Medicare PIN