Provider Demographics
NPI:1104858307
Name:NELSON, KIRSTIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTIN
Middle Name:J
Last Name:NELSON
Suffix:
Gender:F
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:PO BOX 116336
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6336
Mailing Address - Country:US
Mailing Address - Phone:913-352-8346
Mailing Address - Fax:912-355-1414
Practice Address - Street 1:4750 WATERS AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6200
Practice Address - Country:US
Practice Address - Phone:912-352-8346
Practice Address - Fax:912-355-1414
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC400892085R0202X
GA0581212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA123750649AMedicaid
GA123750649BMedicaid
SCG58121Medicaid
SCG58121Medicaid
GA511I940010Medicare PIN
GAP00358213Medicare PIN
GA123750649AMedicaid
GA123750649BMedicaid