Provider Demographics
NPI:1104822204
Name:NELSON, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
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 1:1407 EISENHOWER BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3262
Mailing Address - Country:US
Mailing Address - Phone:814-269-1494
Mailing Address - Fax:814-266-8572
Practice Address - Street 1:1407 EISENHOWER BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3262
Practice Address - Country:US
Practice Address - Phone:814-269-1494
Practice Address - Fax:814-266-8572
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032303E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA149387Medicare ID - Type Unspecified
A35232Medicare UPIN