MEDICARE: DR. JOHN JEFFREY NELSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	034771	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376540005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN JEFFREY NELSON M.D.

Provider Business Mailing Address
First Line	:	11 MAIN ST UNIT 11-205
Second Line	:
City	:	MYSTIC
State	:	CT
Zip	:	06355-3654
Country	:	US
Telephone Number	:	860-421-1090
Fax Number	:	860-421-1091

Provider Business Practice Location Address
First Line	:	11 MAIN ST UNIT 11-205
Second Line	:
City	:	MYSTIC
State	:	CT
Zip	:	06355-3654
Country	:	US
Telephone Number	:	860-421-1090
Fax Number	:	860-421-1091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/11/2024

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