Provider Demographics
NPI:1043221351
Name:NELSON, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W CENTRAL RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2402
Mailing Address - Country:US
Mailing Address - Phone:847-253-4040
Mailing Address - Fax:847-253-3028
Practice Address - Street 1:1100 W CENTRAL RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2402
Practice Address - Country:US
Practice Address - Phone:847-253-4040
Practice Address - Fax:847-253-3028
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095140207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL96398Medicare PIN
G63109Medicare UPIN
ILL76183Medicare PIN