Basic Information
Provider Information | |||||||||
NPI: | 1679835748 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAKSYMIW | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | PRESTIANO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRESTIANO | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 80 PHOENIX AVE 201 | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067021418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037568021 | ||||||||
FaxNumber: | 2035969038 | ||||||||
Practice Location | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060300001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606794017 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2012 | ||||||||
LastUpdateDate: | 07/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 054258 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.