Healthcare Provider Details

I. General information

NPI: 1780813592
Provider Name (Legal Business Name): LARS SPENCER NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 LPGA BLVD SUITE 250
DAYTONA BEACH FL
32117-7130
US

IV. Provider business mailing address

11945 SAN JOSE BLVD SUITE 300
JACKSONVILLE FL
32223-1613
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-0250
  • Fax: 386-274-0268
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-399-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME123398
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberME123398
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME123398
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: