Provider Demographics
NPI:1306934278
Name:NELLESSEN, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:NELLESSEN
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 1:2101 S ARLINGTON HEIGHTS RD
Mailing Address - Street 2:#108
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-4185
Mailing Address - Country:US
Mailing Address - Phone:847-439-4343
Mailing Address - Fax:847-439-4510
Practice Address - Street 1:2101 S ARLINGTON HEIGHTS RD
Practice Address - Street 2:#108
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4185
Practice Address - Country:US
Practice Address - Phone:847-439-4343
Practice Address - Fax:847-439-4510
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-071727Medicaid
F18523Medicare UPIN
968340Medicare ID - Type Unspecified