Healthcare Provider Details

I. General information

NPI: 1356336382
Provider Name (Legal Business Name): ROBERT NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COUNTRY CLUB RD SUITE #205
ROSWELL NM
88201-5205
US

IV. Provider business mailing address

405 W COUNTRY CLUB RD C/O MSO ADMINISTRATION
ROSWELL NM
88201-5209
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-7593
  • Fax: 575-622-5538
Mailing address:
  • Phone: 575-622-7593
  • Fax: 575-622-5538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD00029981
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD2013-0026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: