Healthcare Provider Details

I. General information

NPI: 1417901794
Provider Name (Legal Business Name): THOMAS NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MAIN ST
RUTHERFORD TN
38369-9711
US

IV. Provider business mailing address

17 QUAIL RDG
TRENTON TN
38382-4000
US

V. Phone/Fax

Practice location:
  • Phone: 731-665-7741
  • Fax:
Mailing address:
  • Phone: 731-855-4283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29728
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: