Provider Demographics
NPI:1033354303
Name:NELSON, DAVID LEROY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEROY
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 1:1825 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-3219
Mailing Address - Country:US
Mailing Address - Phone:608-873-6077
Mailing Address - Fax:
Practice Address - Street 1:1825 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-3219
Practice Address - Country:US
Practice Address - Phone:608-873-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine