Healthcare Provider Details

I. General information

NPI: 1366425449
Provider Name (Legal Business Name): DAVID L NELSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 N STATE ST
GENESEO IL
61254-1236
US

IV. Provider business mailing address

241 N STATE ST
GENESEO IL
61254-1236
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-5546
  • Fax: 309-944-8267
Mailing address:
  • Phone: 309-944-5546
  • Fax: 309-944-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: