Healthcare Provider Details

I. General information

NPI: 1235299819
Provider Name (Legal Business Name): DANIEL R NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 CLINIC AVE
CARROLLTON GA
30117-4414
US

IV. Provider business mailing address

156 CLINIC AVE
CARROLLTON GA
30117-4414
US

V. Phone/Fax

Practice location:
  • Phone: 770-214-2229
  • Fax: 770-214-9691
Mailing address:
  • Phone: 770-214-2229
  • Fax: 770-214-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number032005
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: