Provider Demographics
NPI:1154461614
Name:NEILSON, EVAN ROGER (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ROGER
Last Name:NEILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ANNUSKEMUNNICA RD
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-4402
Mailing Address - Country:US
Mailing Address - Phone:631-539-6050
Mailing Address - Fax:
Practice Address - Street 1:99 E MAIN ST
Practice Address - Street 2:SUITE # 3
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2538
Practice Address - Country:US
Practice Address - Phone:631-581-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52953Medicare UPIN
NYX26941Medicare ID - Type Unspecified