Healthcare Provider Details

I. General information

NPI: 1205213378
Provider Name (Legal Business Name): PHILLIP NIELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 SE SALERNO RD STE 200
STUART FL
34997-6572
US

IV. Provider business mailing address

2150 SE SALERNO RD STE 200
STUART FL
34997-6572
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-5757
  • Fax:
Mailing address:
  • Phone: 772-223-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMM15440
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberM154400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: