Healthcare Provider Details

I. General information

NPI: 1306030549
Provider Name (Legal Business Name): EUSTUS S NELSON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 SUN N LAKE BLVD
SEBRING FL
33872-2158
US

IV. Provider business mailing address

4215 SUN N LAKE BLVD
SEBRING FL
33872-2158
US

V. Phone/Fax

Practice location:
  • Phone: 863-382-2248
  • Fax: 863-382-1242
Mailing address:
  • Phone: 863-382-2248
  • Fax: 863-382-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME45558
License Number StateFL

VIII. Authorized Official

Name: MRS. NOREEN M NELSON
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 863-382-2248