Healthcare Provider Details

I. General information

NPI: 1639419385
Provider Name (Legal Business Name): JEROM NELSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 10TH ST
ALAMOGORDO NM
88310-6414
US

IV. Provider business mailing address

1124 10TH ST
ALAMOGORDO NM
88310-6414
US

V. Phone/Fax

Practice location:
  • Phone: 575-434-1200
  • Fax: 575-437-3947
Mailing address:
  • Phone: 575-434-1200
  • Fax: 575-437-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100286
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number673
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: