Provider Demographics
NPI:1720061724
Name:NEILSON, J WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:WILLIAM
Last Name:NEILSON
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:PO BOX 2533
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79105-2533
Mailing Address - Country:US
Mailing Address - Phone:806-212-6640
Mailing Address - Fax:806-212-6278
Practice Address - Street 1:6 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4136
Practice Address - Country:US
Practice Address - Phone:806-353-6604
Practice Address - Fax:806-359-0938
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6992208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX883660Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH ENTERP
D67500Medicare UPIN