Provider Demographics
NPI:1205829421
Name:NELSON, GEORGE RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RICHARD
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SW BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3402
Mailing Address - Country:US
Mailing Address - Phone:503-227-5949
Mailing Address - Fax:503-227-3621
Practice Address - Street 1:611 SW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3402
Practice Address - Country:US
Practice Address - Phone:503-227-5949
Practice Address - Fax:503-227-3621
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1189T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62949Medicare UPIN