Healthcare Provider Details

I. General information

NPI: 1215018486
Provider Name (Legal Business Name): CARY D NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12626 RIVERSIDE DR STE 510
VALLEY VILLAGE CA
91607-3463
US

IV. Provider business mailing address

PO BOX 3341
LONG BEACH CA
90803-0341
US

V. Phone/Fax

Practice location:
  • Phone: 818-755-0101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA87420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: