Provider Demographics
NPI:1366481806
Name:NIELSEN, DOUGLAS BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRENT
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: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:801-294-1080
Mailing Address - Fax:801-292-8369
Practice Address - Street 1:390 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6046
Practice Address - Country:US
Practice Address - Phone:801-294-1080
Practice Address - Fax:801-292-8369
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1648271205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057086Medicaid
UTG80806Medicare UPIN
UT942854057086Medicaid