Provider Demographics
NPI:1700225679
Name:NIELSON, MICHAEL RAY (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 W. 100 NORTH
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535
Mailing Address - Country:US
Mailing Address - Phone:435-587-2116
Mailing Address - Fax:
Practice Address - Street 1:380 W. 100 NORTH
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535
Practice Address - Country:US
Practice Address - Phone:435-587-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9551857-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine