Provider Demographics
NPI:1285659367
Name:NIELSEN, DAVID A (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 TALIESEN LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1519
Mailing Address - Country:US
Mailing Address - Phone:815-399-1392
Mailing Address - Fax:
Practice Address - Street 1:1641 N ALPINE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1458
Practice Address - Country:US
Practice Address - Phone:815-397-5337
Practice Address - Fax:815-397-5540
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT33504Medicare UPIN
IL212809Medicare ID - Type Unspecified