Healthcare Provider Details

I. General information

NPI: 1619207941
Provider Name (Legal Business Name): RICHARD L NIELSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 20
FORT WAYNE IN
46845-1733
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6940
  • Fax: 260-425-6949
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01025422A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01025422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: