Provider Demographics
NPI:1114966611
Name:NYQUIST, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:NYQUIST
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 1:4500 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-6220
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-257-6220
Practice Address - Fax:618-257-6679
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36076188207Q00000X
IL036-076188208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
187771OtherHEALTH LINK
0104775OtherUNITED HEALTH CARE UHC
080174497OtherRAILROAD MEDICARE
IL036076188Medicaid
133289OtherCMR A DIVISION OF GHP
IL006015346OtherBLUE CROSS BLUE SHIELD OF
4080250OtherAETNA
133289OtherGROUP HEALTH PLAN GHP
133289OtherCMR A DIVISION OF GHP
187771OtherHEALTH LINK