Provider Demographics
NPI:1164660650
Name:MARK D NELSON, DPM, LLC
Entity Type:Organization
Organization Name:MARK D NELSON, DPM, LLC
Other - Org Name:MARK D NELSON, DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDEN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-725-4008
Mailing Address - Street 1:1440 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4638
Mailing Address - Country:US
Mailing Address - Phone:920-725-4008
Mailing Address - Fax:920-725-4218
Practice Address - Street 1:1440 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4638
Practice Address - Country:US
Practice Address - Phone:920-725-4008
Practice Address - Fax:920-725-4218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI862025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI862025OtherLICENSE
WI862025OtherLICENSE