Provider Demographics
NPI:1538106125
Name:NIELSEN, RICHARD CRAIG
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CRAIG
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:R. CRAIG
Other - Middle Name:
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1021 PALM BROOK DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1618
Mailing Address - Country:US
Mailing Address - Phone:570-419-4446
Mailing Address - Fax:321-600-4457
Practice Address - Street 1:1021 PALM BROOK DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1618
Practice Address - Country:US
Practice Address - Phone:570-419-4446
Practice Address - Fax:321-600-4457
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
029065Medicare ID - Type Unspecified