Healthcare Provider Details

I. General information

NPI: 1427091065
Provider Name (Legal Business Name): DOUGLAS NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 BURNS WAY
KALISPELL MT
59901-3109
US

IV. Provider business mailing address

1287 BURNS WAY
KALISPELL MT
59901-3109
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8120
  • Fax: 406-752-8134
Mailing address:
  • Phone: 406-752-8120
  • Fax: 406-752-8134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7105
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number7105
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: