Healthcare Provider Details

I. General information

NPI: 1124188875
Provider Name (Legal Business Name): MICHAEL R NELSON M.D.,PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 IVY RD STE 311
CHARLOTTESVILLE VA
22903-9353
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-2227
  • Fax: 434-244-4503
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number0101051770
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: