Provider Demographics
NPI:1306865183
Name:NELSON, ELIOT W (MD)
Entity Type:Individual
Prefix:
First Name:ELIOT
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 FOUR SISTERS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-8115
Mailing Address - Country:US
Mailing Address - Phone:802-658-6024
Mailing Address - Fax:
Practice Address - Street 1:353 BLAIR PARK RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7530
Practice Address - Country:US
Practice Address - Phone:802-847-1440
Practice Address - Fax:802-847-3014
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0035Medicaid
NYE01228106Medicaid
NYE01228106Medicaid