Provider Demographics
NPI:1326069832
Name:NIELSEN, ROBERT ORVILLE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ORVILLE
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:O
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-535-8163
Mailing Address - Fax:801-355-4011
Practice Address - Street 1:333 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:801-535-8163
Practice Address - Fax:801-355-4011
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT154472-1205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E14357Medicare UPIN