Provider Demographics
NPI:1568458479
Name:NIELAN, GARY JOHN
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:NIELAN
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 1:2207 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1155
Mailing Address - Country:US
Mailing Address - Phone:413-599-1201
Mailing Address - Fax:413-596-2940
Practice Address - Street 1:2207 BOSTON RD
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1155
Practice Address - Country:US
Practice Address - Phone:413-599-1201
Practice Address - Fax:413-596-2940
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1550582080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017078OtherAETNA/USHC
155058OtherMA LICENSE
23378OtherHEALTH NEW ENGLAND
28036OtherCHILDRENS MEDICAL SECURIT
353451OtherHEALTHSOURCE MA NH
J18133OtherBCBS
102170OtherCIGNA
1550588404OtherCONNECTICARE
MA3182916Medicaid
1204585OtherUNITED HEALTHCARE
155058OtherTUFTS
975887OtherNETWORK HEALTH
010155058MA01OtherANTHEM BCBS
201928OtherHARVARD PILGRIM
000000008141OtherBOSTON MED CENTER HEALTH
000000008141OtherBOSTON MED CENTER HEALTH
155058OtherMA LICENSE