Provider Demographics
NPI:1174510788
Name:NATHAN, NEIL J (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:J
Last Name:NATHAN
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 1:3471 REGIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8209
Mailing Address - Country:US
Mailing Address - Phone:707-575-5180
Mailing Address - Fax:
Practice Address - Street 1:3471 REGIONAL PKWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8209
Practice Address - Country:US
Practice Address - Phone:707-575-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5C40207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00140692OtherRR MEDICARE
D75824Medicare UPIN
942520115Medicare ID - Type Unspecified