Provider Demographics
NPI:1548379605
Name:NILSON, BJORN
Entity Type:Individual
Prefix:
First Name:BJORN
Middle Name:
Last Name:NILSON
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 1:5505 E BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5305
Mailing Address - Country:US
Mailing Address - Phone:559-251-4913
Mailing Address - Fax:
Practice Address - Street 1:4460 E HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2962
Practice Address - Country:US
Practice Address - Phone:559-459-4300
Practice Address - Fax:559-459-4569
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC35140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C351400Medicaid
CA00C351400Medicaid
CA00C351400Medicare ID - Type Unspecified