Provider Demographics
NPI:1841667383
Name:NILES, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:NILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 S BROAD ST
Mailing Address - Street 2:1D
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6600
Mailing Address - Country:US
Mailing Address - Phone:203-630-3634
Mailing Address - Fax:203-639-0809
Practice Address - Street 1:546 S BROAD ST
Practice Address - Street 2:1D
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6600
Practice Address - Country:US
Practice Address - Phone:203-630-3634
Practice Address - Fax:203-639-0809
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLO001309156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician