Healthcare Provider Details

I. General information

NPI: 1053376889
Provider Name (Legal Business Name): LOREN DOUGLAS NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 FLAT CREEK DR # 3999
JACKSON WY
83001-9173
US

IV. Provider business mailing address

PO BOX 3999
JACKSON WY
83001-3999
US

V. Phone/Fax

Practice location:
  • Phone: 305-542-9038
  • Fax:
Mailing address:
  • Phone: 305-542-9038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME69015
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberTL2018
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: