Healthcare Provider Details

I. General information

NPI: 1205451101
Provider Name (Legal Business Name): KRISTOPHER NELSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 S DAVIS RD STE E
LAGRANGE GA
30241-2588
US

IV. Provider business mailing address

380 S DAVIS RD STE E
LAGRANGE GA
30241-2588
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-8831
  • Fax:
Mailing address:
  • Phone: 706-882-8831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number12026
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: