Healthcare Provider Details

I. General information

NPI: 1396712295
Provider Name (Legal Business Name): VINCENT T NISHINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 NEPONSET ST
WORCESTER MA
01606-2714
US

IV. Provider business mailing address

5 NEPONSET ST WOT 2ND FL, STE C203
WORCESTER MA
01606-2714
US

V. Phone/Fax

Practice location:
  • Phone: 508-368-7887
  • Fax: 508-792-4392
Mailing address:
  • Phone: 508-368-7887
  • Fax: 508-792-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51532
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: