Provider Demographics
NPI:1285634469
Name:NELSON, BRADLEY D (DPM)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601
Mailing Address - Country:US
Mailing Address - Phone:580-323-5800
Mailing Address - Fax:580-323-5802
Practice Address - Street 1:207 S 30TH STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601
Practice Address - Country:US
Practice Address - Phone:580-323-5800
Practice Address - Fax:580-323-5802
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK230213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200026910AMedicaid
OK5158640002Medicare NSC
OK200026910AMedicaid
OK242418400Medicare PIN
OK5158640001Medicare NSC
U99921Medicare UPIN