Provider Demographics
NPI:1245229954
Name:NELSON, KEITH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2310 N 400 E
Mailing Address - Street 2:STE A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1788
Mailing Address - Country:US
Mailing Address - Phone:435-787-2000
Mailing Address - Fax:435-787-1913
Practice Address - Street 1:2310 N 400 E
Practice Address - Street 2:STE A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1788
Practice Address - Country:US
Practice Address - Phone:435-787-2000
Practice Address - Fax:435-787-1913
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-06-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT5924248-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5166950001Medicare NSC
UTG36852Medicare UPIN