Provider Demographics
NPI:1164464301
Name:NELSON, CAROLYN D (DO)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32756 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3133
Practice Address - Country:US
Practice Address - Phone:248-476-3280
Practice Address - Fax:248-476-3286
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH26459OtherBLUE CROSS
MI139928OtherCARE CHOICES
MI4033266OtherAETNA
MI3323613Medicaid
MIB0411OtherMCARE
MIFV4454280Medicaid
MIOH26459OtherBLUE CROSS
MI4033266OtherAETNA