Healthcare Provider Details

I. General information

NPI: 1720061724
Provider Name (Legal Business Name): J WILLIAM NEILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MEDICAL DR
AMARILLO TX
79106-4136
US

IV. Provider business mailing address

PO BOX 2533
AMARILLO TX
79105-2533
US

V. Phone/Fax

Practice location:
  • Phone: 806-353-6604
  • Fax: 806-359-0938
Mailing address:
  • Phone: 806-212-6640
  • Fax: 806-212-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberF6992
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: