Healthcare Provider Details

I. General information

NPI: 1861499964
Provider Name (Legal Business Name): JOHANNES CHRISTIAN NUNNINK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

PO BOX 1063 111 COLCHESTER AVE
BURLINGTON VT
05402-1063
US

V. Phone/Fax

Practice location:
  • Phone: 802-656-0546
  • Fax:
Mailing address:
  • Phone: 802-847-5465
  • Fax: 802-656-5493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number042-0006659
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: