Healthcare Provider Details

I. General information

NPI: 1568813269
Provider Name (Legal Business Name): LANCE RONALD NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N DAYTON ST
CHICAGO IL
60642-2644
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 319-384-7888
  • Fax: 319-384-7899
Mailing address:
  • Phone: 239-343-6788
  • Fax: 239-343-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036.160891
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME175958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: