Healthcare Provider Details

I. General information

NPI: 1720083421
Provider Name (Legal Business Name): RAYMOND E WINICKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GRANDVIEW AVE STE 201
WATERBURY CT
06708-2520
US

IV. Provider business mailing address

171 GRANDVIEW AVE SUITE 201
WATERBURY CT
06708-2520
US

V. Phone/Fax

Practice location:
  • Phone: 203-578-4630
  • Fax: 203-578-4629
Mailing address:
  • Phone: 203-578-4630
  • Fax: 203-578-4629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number040374
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: