Healthcare Provider Details

I. General information

NPI: 1487656344
Provider Name (Legal Business Name): MARK D NELSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HART BLVD STE 100
MONTICELLO MN
55362-8929
US

IV. Provider business mailing address

1700 HIGHWAY 25 N
BUFFALO MN
55313-1930
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-2921
  • Fax: 763-271-3803
Mailing address:
  • Phone: 763-682-1313
  • Fax: 763-581-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number862-025
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number706
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: