Provider Demographics
NPI:1518078989
Name:NIELSEN, BRENT C (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
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 1:1005 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9494
Mailing Address - Country:US
Mailing Address - Phone:309-799-8818
Mailing Address - Fax:
Practice Address - Street 1:4540 3RD ST
Practice Address - Street 2:THE EYE CENTER
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6104
Practice Address - Country:US
Practice Address - Phone:309-797-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
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
MN0597321OtherDEA REGISTRATION NUMBER
T35352Medicare UPIN