Provider Demographics
NPI:1861691685
Name:CRAIG L. NIELSEN, O.D.
Entity type:Organization
Organization Name:CRAIG L. NIELSEN, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-235-9519
Mailing Address - Street 1:105 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6516
Mailing Address - Country:US
Mailing Address - Phone:203-235-9519
Mailing Address - Fax:203-237-3819
Practice Address - Street 1:105 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6516
Practice Address - Country:US
Practice Address - Phone:203-235-9519
Practice Address - Fax:203-237-3819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004086650Medicaid
CT0366880001Medicare NSC
CT004086650Medicaid
CTC00543Medicare PIN