Provider Demographics
NPI:1053503961
Name:NIELSON, DAVID LAMONT (DPM)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LAMONT
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:222 WALNUT AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4723
Mailing Address - Country:US
Mailing Address - Phone:540-344-3668
Mailing Address - Fax:540-769-6381
Practice Address - Street 1:222 WALNUT AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4723
Practice Address - Country:US
Practice Address - Phone:540-344-3668
Practice Address - Fax:540-769-6381
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300976213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053503961Medicaid
VA1053503961Medicaid
VA017444F35Medicare PIN
VA5715980001Medicare NSC