MEDICARE: DR. CHARLES L NELSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TX2272	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17473	OTHER		SPECTERA
2	27975	OTHER		AVESIS

General Provider Information

NPI Number	:	1285792663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES L NELSON OD

Provider Business Mailing Address
First Line	:	5235 B WALZEM
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-2122
Country	:	US
Telephone Number	:	210-657-2020
Fax Number	:	210-657-2028

Provider Business Practice Location Address
First Line	:	5235 B WALZEM
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-2122
Country	:	US
Telephone Number	:	210-657-2020
Fax Number	:	210-657-2028

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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