Provider Demographics
NPI:1952390338
Name:NEILSON, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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 1:855 MANKATO AVE
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-4868
Mailing Address - Country:US
Mailing Address - Phone:507-454-3650
Mailing Address - Fax:507-474-3392
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4868
Practice Address - Country:US
Practice Address - Phone:507-454-3650
Practice Address - Fax:507-474-3392
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4594207R00000X
MN52693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78718OtherPRESBYTERIAN COMMERCIAL
TX86723ZOtherHMO BLUE
TX151183401Medicaid
NM77871367Medicaid
OK100159800AMedicaid
TX131010101OtherFIRSTCARE COMMERCIAL
NMA535OtherTRIWEST
TX8B2602OtherBC/BS
NM78718Medicaid
TX131010100Medicaid
TXH61151Medicare UPIN
TX86723ZOtherHMO BLUE
TX151183401Medicaid