Provider Demographics
NPI:1790873164
Name:NIELSEN, MARK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 1ST ST N APT 1202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-9109
Mailing Address - Country:US
Mailing Address - Phone:936-544-4498
Mailing Address - Fax:
Practice Address - Street 1:917 1ST ST N APT 1202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-9109
Practice Address - Country:US
Practice Address - Phone:936-544-4498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME161324208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C19907Medicare UPIN
TX84591FMedicare PIN