Provider Demographics
NPI:1821385774
Name:BROLIS, NILS VIESTURS (DO)
Entity Type:Individual
Prefix:DR
First Name:NILS
Middle Name:VIESTURS
Last Name:BROLIS
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 1:1474 TANYARD ROAD
Mailing Address - Street 2:SUITE D100
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080
Mailing Address - Country:US
Mailing Address - Phone:856-566-6265
Mailing Address - Fax:856-566-6185
Practice Address - Street 1:1474 TANYARD ROAD
Practice Address - Street 2:SUITE D100
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-566-6265
Practice Address - Fax:856-566-6185
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09374700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ678445OtherMEDICARE
NJ0473570Medicaid