Provider Demographics
NPI:1912952243
Name:NISBETH, HEATHER M (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:NISBETH
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 1:22 OLD WATERBURY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3848
Mailing Address - Country:US
Mailing Address - Phone:203-264-6503
Mailing Address - Fax:203-262-1430
Practice Address - Street 1:22 OLD WATERBURY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3848
Practice Address - Country:US
Practice Address - Phone:203-264-6503
Practice Address - Fax:203-262-1430
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032576207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004394532Medicaid
CT004394532Medicaid
CT110006376Medicare ID - Type Unspecified