Provider Demographics
NPI:1114007051
Name:NIELSEN, BUDDY R (MD)
Entity Type:Individual
Prefix:
First Name:BUDDY
Middle Name:R
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E MOCKINGBIRD LN
Mailing Address - Street 2:STE 101
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2178
Mailing Address - Country:US
Mailing Address - Phone:361-573-6291
Mailing Address - Fax:361-576-2434
Practice Address - Street 1:1501 E MOCKINGBIRD LN
Practice Address - Street 2:#101
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2155
Practice Address - Country:US
Practice Address - Phone:361-573-6291
Practice Address - Fax:361-576-2434
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8074207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138596501Medicaid
TXMDJ8074OtherWORKER COMPENSATION
TX742710179A012OtherCHAMPUS
TX87W152OtherBLUE CROSS
TX87W152Medicare PIN
TX87W152Medicare ID - Type Unspecified