Provider Demographics
NPI:1730187162
Name:VIVIANO, NICHOLAS JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:VIVIANO
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 1259
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1259
Mailing Address - Country:US
Mailing Address - Phone:985-893-9464
Mailing Address - Fax:
Practice Address - Street 1:7031 HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4955
Practice Address - Country:US
Practice Address - Phone:985-893-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015859207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB61535Medicare UPIN