Healthcare Provider Details

I. General information

NPI: 1366481806
Provider Name (Legal Business Name): DOUGLAS BRENT NIELSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N MAIN ST
BOUNTIFUL UT
84010-6046
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-294-1080
  • Fax: 801-292-8369
Mailing address:
  • Phone: 801-294-1080
  • Fax: 801-292-8369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1648271205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: