Provider Demographics
NPI:1346356219
Name:NELSON, JAMES (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:1773 WOODSIDE TRL NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2580
Mailing Address - Country:US
Mailing Address - Phone:616-453-1835
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:4845 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-4498
Practice Address - Country:US
Practice Address - Phone:616-531-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001738213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3071580Medicaid
MI0M00840Medicare ID - Type UnspecifiedMEDICARE
MIU48385Medicare UPIN
MI3071580Medicaid