Provider Demographics
NPI:1033234307
Name:NELSON, JERRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4805
Mailing Address - Country:US
Mailing Address - Phone:559-459-1845
Mailing Address - Fax:
Practice Address - Street 1:2111 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4805
Practice Address - Country:US
Practice Address - Phone:559-459-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21897207ZF0201X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Not Answered207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A218970Medicaid
00A218970Medicare ID - Type UnspecifiedMEDICARE
A22818Medicare UPIN