1083613830 NPI number — DALE E NELSON OD

Table of content: DALE E NELSON OD (NPI 1083613830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083613830 NPI number — DALE E NELSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
DALE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083613830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4690 W ARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55384-9703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-471-0562
Provider Business Mailing Address Fax Number:
888-770-8024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 GREELEY AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENCOE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55336-2103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-864-6111
Provider Business Practice Location Address Fax Number:
320-864-6134
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1525 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22-16206 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 602523400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 964661001450 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12370NE . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2202730 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 040512010 . This is a "METROPOLITAN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 22-02730 . This is a "SELECT CARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com