=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720061724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | J WILLIAM NEILSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 MEDICAL DR
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-4136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-353-6604
-----------------------------------------------------
Fax | 806-359-0938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2533
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79105-2533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-212-6640
-----------------------------------------------------
Fax | 806-212-6278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | F6992
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------