Provider Demographics
NPI:1245264258
Name:NICHELE, MAURIZIO DOMENICO
Entity type:Individual
Prefix:DR
First Name:MAURIZIO
Middle Name:DOMENICO
Last Name:NICHELE
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 1:929 BOSTON POST RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2143
Mailing Address - Country:US
Mailing Address - Phone:860-395-0554
Mailing Address - Fax:860-395-0448
Practice Address - Street 1:929 BOSTON POST RD
Practice Address - Street 2:SUITE 1
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2143
Practice Address - Country:US
Practice Address - Phone:860-395-0554
Practice Address - Fax:860-395-0448
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034772208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG57911Medicare UPIN