Healthcare Provider Details

I. General information

NPI: 1891964615
Provider Name (Legal Business Name): JOHN WILLIAM NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 HAWTHORNE PARK
RALEIGH NC
27613-6006
US

IV. Provider business mailing address

5524 HAWTHORNE PARK
RALEIGH NC
27613-6006
US

V. Phone/Fax

Practice location:
  • Phone: 919-870-0057
  • Fax:
Mailing address:
  • Phone: 919-621-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number200400068
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: