=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376682344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK H NELSON MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 HIGHLAND OAKS DR SUITE 100
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-659-1528
-----------------------------------------------------
Fax | 336-659-1980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 HIGHLAND OAKS DR SUITE 100
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-659-1528
-----------------------------------------------------
Fax | 336-659-1980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK H NELSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-659-1528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 33109
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------