Healthcare Provider Details

I. General information

NPI: 1982601530
Provider Name (Legal Business Name): CARL W NISSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SEYMOUR ST STE 204
HARTFORD CT
06106-5505
US

IV. Provider business mailing address

31 PINNACLE RIDGE RD
FARMINGTON CT
06032-3041
US

V. Phone/Fax

Practice location:
  • Phone: 860-421-3233
  • Fax:
Mailing address:
  • Phone: 860-421-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number033613
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number033613
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number33613
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: