Healthcare Provider Details

I. General information

NPI: 1598735375
Provider Name (Legal Business Name): MICHAEL NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8528
  • Fax: 505-823-8555
Mailing address:
  • Phone: 505-823-8528
  • Fax: 505-823-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number72-204
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: