Basic Information
| Provider Information | |||||||||
| NPI: | 1548293822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEILSON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 E CAMBRIDGE AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029334363 | ||||||||
| FaxNumber: | 6029332415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 35-083650 | OH | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207SG0201X | 56355 | AZ | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 000000224312 | 01 | OH | UNISON | OTHER | 000000340115 | 01 | OH | ANTHEM | OTHER | 2499952 | 05 | OH | MEDICAID | 7841606 | 01 | OH | AETNA | OTHER | 000000529594 | 01 | OH | ANTHEM | OTHER | 363878 | 01 | OH | WELLCARE | OTHER | 745996 | 01 | OH | BUCKEYE | OTHER |