Provider Demographics
NPI:1417112715
Name:CHRISTIAN D NILSON MD PC
Entity Type:Organization
Organization Name:CHRISTIAN D NILSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-752-2020
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:STE T
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-752-2020
Mailing Address - Fax:435-752-5475
Practice Address - Street 1:550 E 1400 N STE P
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2450
Practice Address - Country:US
Practice Address - Phone:435-752-2020
Practice Address - Fax:435-752-5475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT69626121205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT08111972OtherOWNERS DOB
UT08111972OtherOWNERS DOB