Basic Information
| Provider Information | |||||||||
| NPI: | 1417112715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN D NILSON MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 E 1400 N | ||||||||
| Address2: | STE T | ||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357522020 | ||||||||
| FaxNumber: | 4357525475 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 E 1400 N STE P | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357522020 | ||||||||
| FaxNumber: | 4357525475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | NILSON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4357522020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 69626121205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 08111972 | 01 | UT | OWNERS DOB | OTHER |