Provider Demographics
NPI:1083613830
Name:NELSON, DALE E (OD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:E
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4690 W ARM RD
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9703
Mailing Address - Country:US
Mailing Address - Phone:952-471-0562
Mailing Address - Fax:888-770-8024
Practice Address - Street 1:1234 GREELEY AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2103
Practice Address - Country:US
Practice Address - Phone:320-864-6111
Practice Address - Fax:320-864-6134
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22-16206OtherMEDICA
MN602523400Medicaid
964661001450OtherPREFERRED ONE
12370NEOtherBCBS
2202730OtherMEDICA
040512010OtherMETROPOLITAN HEALTH PLAN
22-02730OtherSELECT CARE
T39998Medicare UPIN
040512010OtherMETROPOLITAN HEALTH PLAN
964661001450OtherPREFERRED ONE