Provider Demographics
NPI:1376541805
Name:NELSON, ERIC REYNOLD (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:REYNOLD
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 1:3101 CLEARWATER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7180
Mailing Address - Country:US
Mailing Address - Phone:928-776-1004
Mailing Address - Fax:928-776-1276
Practice Address - Street 1:3101 CLEARWATER DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7180
Practice Address - Country:US
Practice Address - Phone:928-776-1004
Practice Address - Fax:928-776-1276
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29418208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ589286Medicaid
AZ589286Medicaid
AZ68103Medicare ID - Type Unspecified