Provider Demographics
NPI:1548293822
Name:NEILSON, DEREK E (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:E
Last Name:NEILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:1920 E CAMBRIDGE AVE STE 304
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-933-4363
Practice Address - Fax:602-933-2415
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-083650207SG0201X
AZ56355207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000224312OtherUNISON
OH000000340115OtherANTHEM
OH2499952Medicaid
OH7841606OtherAETNA
OH000000529594OtherANTHEM
OH363878OtherWELLCARE
OH745996OtherBUCKEYE
OHI16974Medicare UPIN
OHNE4143151Medicare PIN
OH2499952Medicaid