Provider Demographics
NPI:1205980778
Name:NIELSEN, DANIEL A (OD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:A
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:OPTOMETRY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3150
Practice Address - Fax:217-383-4845
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009298152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410043693OtherPALMETTO GBA
U81429Medicare UPIN
ILL79985Medicare PIN