Provider Demographics
NPI:1134665797
Name:NELSON, MARY MARKS
Entity Type:Individual
Prefix:
First Name:MARY MARKS
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 1ST ST BLDG 46
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73523-5004
Mailing Address - Country:US
Mailing Address - Phone:580-481-5623
Mailing Address - Fax:580-481-1321
Practice Address - Street 1:301 N 1ST ST # 46
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3634208000000X
ALDO.2405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics