Provider Demographics
NPI:1295036697
Name:NELSON, JEFFREY THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:THOMAS
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 BACK STAGE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE BUENA VISTA
Mailing Address - State:FL
Mailing Address - Zip Code:32830-8472
Mailing Address - Country:US
Mailing Address - Phone:407-934-4100
Mailing Address - Fax:407-934-4101
Practice Address - Street 1:960 BACK STAGE LN
Practice Address - Street 2:
Practice Address - City:LAKE BUENA VISTA
Practice Address - State:FL
Practice Address - Zip Code:32830-8472
Practice Address - Country:US
Practice Address - Phone:407-934-4100
Practice Address - Fax:407-934-4101
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGX544XMedicare PIN