Provider Demographics
NPI:1174630958
Name:NIELSEN, JEFFREY EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:EDWIN
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 1:27W685 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-377-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36073158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE43618Medicare UPIN