Healthcare Provider Details

I. General information

NPI: 1295720936
Provider Name (Legal Business Name): JEFFREY DONALD NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT EXT UNIVERSITY HEALTH SERVICE- CLINICAL SERVICES
BERKELEY CA
94720-4303
US

IV. Provider business mailing address

PO BOX 4446
BERKELEY CA
94704-0446
US

V. Phone/Fax

Practice location:
  • Phone: 510-643-7110
  • Fax: 510-643-9790
Mailing address:
  • Phone: 510-642-7955
  • Fax: 510-643-6999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG72339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: