Provider Demographics
NPI:1225015670
Name:NELSON, MARY ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANNE
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 1:411 10TH ST SE
Mailing Address - Street 2:STE 1400
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2467
Mailing Address - Country:US
Mailing Address - Phone:319-365-8616
Mailing Address - Fax:319-297-7377
Practice Address - Street 1:411 10TH ST SE
Practice Address - Street 2:STE 1400
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2467
Practice Address - Country:US
Practice Address - Phone:319-365-8616
Practice Address - Fax:319-297-7377
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0156794Medicaid
A14503Medicare ID - Type Unspecified
A14503Medicare UPIN