Healthcare Provider Details

I. General information

NPI: 1891737763
Provider Name (Legal Business Name): MARK ALBERT NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 I ST FL 2
LA PORTE IN
46350-5533
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-6566
  • Fax: 219-872-2712
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01040264A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: