Provider Demographics
NPI:1891851820
Name:NIELSEN, RONALD D (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
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 1:2901 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4614
Mailing Address - Country:US
Mailing Address - Phone:253-534-7000
Mailing Address - Fax:253-534-7099
Practice Address - Street 1:2901 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4614
Practice Address - Country:US
Practice Address - Phone:253-534-7000
Practice Address - Fax:253-534-7099
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202679OtherSTATE L&I
WA8115180Medicaid
WA8940121OtherCRIME VICTIMS
WAG8857218Medicare PIN
WAG8865696Medicare PIN
WA8857218Medicare ID - Type Unspecified