Healthcare Provider Details

I. General information

NPI: 1679556591
Provider Name (Legal Business Name): BRADLEY WIMMER NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 DAY ST
RIVERSIDE CA
92507-0901
US

IV. Provider business mailing address

3660 ARLINGTON AVE
RIVERSIDE CA
92506-3912
US

V. Phone/Fax

Practice location:
  • Phone: 951-697-5455
  • Fax: 951-653-3975
Mailing address:
  • Phone: 951-782-5110
  • Fax: 951-274-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG52306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: