Healthcare Provider Details

I. General information

NPI: 1902917495
Provider Name (Legal Business Name): TODD ROBERT NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 E MURRAY HOLLADAY RD
MILLCREEK UT
84117-4901
US

IV. Provider business mailing address

2965 W 3500 S
WEST VALLEY CITY UT
84119-3602
US

V. Phone/Fax

Practice location:
  • Phone: 801-965-3600
  • Fax:
Mailing address:
  • Phone: 801-965-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number365595-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number365595-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: