Healthcare Provider Details

I. General information

NPI: 1023084902
Provider Name (Legal Business Name): BRENT V. NELSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR ADOLESCENT MEDICINE USA MEDDAC, EACH,
FORT CARSON CO
80913-4603
US

IV. Provider business mailing address

630 MAROONGLEN CT
COLORADO SPRINGS CO
80906-6805
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7226
  • Fax:
Mailing address:
  • Phone: 719-576-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberDO407
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: