Provider Demographics
NPI:1376047381
Name:NELSON, RICHARD LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAWRENCE
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 1:1603 WEST TAYLOR ST.
Mailing Address - Street 2:ROOM 983 EPIDEMIOLOGY/BIOMETRY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4394
Mailing Address - Country:US
Mailing Address - Phone:224-410-5592
Mailing Address - Fax:
Practice Address - Street 1:1603 W. TAYLOR ST.
Practice Address - Street 2:ROOM 983
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4394
Practice Address - Country:US
Practice Address - Phone:224-410-5592
Practice Address - Fax:312-996-0064
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048329208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery