Provider Demographics
NPI:1699891374
Name:NIELSON, JEREMIAH JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:JAMES
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2020 ZONAL AVE
Mailing Address - Street 2:IRD# 820
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0121
Mailing Address - Country:US
Mailing Address - Phone:323-226-3406
Mailing Address - Fax:323-226-3440
Practice Address - Street 1:2020 ZONAL AVE
Practice Address - Street 2:IRD# 820
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0121
Practice Address - Country:US
Practice Address - Phone:323-226-3406
Practice Address - Fax:323-226-3440
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-19432080N0001X
CA20A108732080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A10873OtherCA STATE MEDICAL LICENSE
CA20A10873OtherCA STATE MEDICAL LICENSE