Provider Demographics
NPI:1952608077
Name:NIELSEN, MICHAEL W (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4711
Mailing Address - Country:US
Mailing Address - Phone:916-597-6358
Mailing Address - Fax:
Practice Address - Street 1:4501 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8687
Practice Address - Country:US
Practice Address - Phone:925-813-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEF078213ES0103X
NMT-1033213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty