Healthcare Provider Details

I. General information

NPI: 1134151327
Provider Name (Legal Business Name): MICHAEL L NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 76TH ST
MILWAUKEE WI
53223
US

IV. Provider business mailing address

3003 W GOOD HOPE RD
MILWAUKEE WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 414-354-6434
  • Fax: 414-586-5745
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23830
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: