Basic Information
| Provider Information | |||||||||
| NPI: | 1649383027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 837 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973390837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012256246 | ||||||||
| FaxNumber: | 8012251525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 04-33446 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 2008036902 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 11765834-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1649383027 | 05 | UT | MEDICAID |