Provider Demographics
NPI:1649383027
Name:NIELSEN, DAVID B (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0837
Mailing Address - Country:US
Mailing Address - Phone:541-758-5047
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:1055 N 300 W STE 104
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-225-6246
Practice Address - Fax:801-225-1525
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-334462085P0229X
MO20080369022085P0229X
UT11765834-12052085P0229X
OH350780592085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1649383027Medicaid