Provider Demographics
NPI:1417955113
Name:NIELSEN, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3912
Mailing Address - Country:US
Mailing Address - Phone:530-257-4137
Mailing Address - Fax:530-257-4005
Practice Address - Street 1:701 NEVADA ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3912
Practice Address - Country:US
Practice Address - Phone:530-257-4137
Practice Address - Fax:530-257-4005
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2220213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4764610001Medicare NSC