Provider Demographics
NPI:1063494524
Name:NELSON, JEREMIAH (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
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 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:2880 N TENAYA WAY STE 320
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0642
Practice Address - Country:US
Practice Address - Phone:702-862-8226
Practice Address - Fax:702-862-8227
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 92825207RE0101X
IAMD-45607207RE0101X
OH35099088208000000X, 2080P0205X
FLME00928252080P0205X
NV239212080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL297631OtherAMERIGROUP
FL2438274001OtherCIGNA
FL297105OtherSTAYWELL HEALTHY KIDS
FL489063073OtherHUMANA
FL7134730OtherAETNA UNITED
FL16865OtherBCBS
FL16865YMedicare PIN
FL297631OtherAMERIGROUP
FL16865YMedicare PIN