Healthcare Provider Details

I. General information

NPI: 1407039050
Provider Name (Legal Business Name): NICHOLAS J. VIVIANO, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 HIGHWAY 190 EAST SERVICE RD
COVINGTON LA
70433-4955
US

IV. Provider business mailing address

PO BOX 1259
MANDEVILLE LA
70470-1259
US

V. Phone/Fax

Practice location:
  • Phone: 985-893-9464
  • Fax: 985-893-9465
Mailing address:
  • Phone: 985-893-9464
  • Fax: 985-893-9465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number015859
License Number StateLA

VIII. Authorized Official

Name: DR. NICHOLAS JOSEPH VIVIANO
Title or Position: CEO
Credential: MD
Phone: 985-893-9464