Provider Demographics
NPI:1376540005
Name:NELSON, JOHN JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JEFFREY
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 1:276 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4727
Mailing Address - Country:US
Mailing Address - Phone:860-443-7907
Mailing Address - Fax:860-442-6730
Practice Address - Street 1:276 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4727
Practice Address - Country:US
Practice Address - Phone:860-443-7907
Practice Address - Fax:860-442-6730
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001347716Medicaid
CT001347716Medicaid
CT110005808Medicare ID - Type Unspecified