Provider Demographics
NPI:1275714628
Name:NIELSEN UROLOGY
Entity Type:Organization
Organization Name:NIELSEN UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-564-3030
Mailing Address - Street 1:522 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1244
Mailing Address - Country:US
Mailing Address - Phone:936-564-3030
Mailing Address - Fax:
Practice Address - Street 1:522 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1244
Practice Address - Country:US
Practice Address - Phone:936-564-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T15FOtherBLUE CROSS BLUE SHIELD
TX0008BMMedicare PIN