Healthcare Provider Details

I. General information

NPI: 1619904679
Provider Name (Legal Business Name): CHADD DEE NELSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W
RANDOLPH AIR FORCE BASE TX
78150-4800
US

IV. Provider business mailing address

1830 N 145TH AVE APT 1001
GOODYEAR AZ
85395-5402
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-6403
  • Fax:
Mailing address:
  • Phone: 801-678-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number285235-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number285235-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: