Provider Demographics
NPI:1376607176
Name:NELSON, JOHN C (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15909 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-4720
Mailing Address - Country:US
Mailing Address - Phone:626-961-0876
Mailing Address - Fax:909-468-4603
Practice Address - Street 1:15909 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-4720
Practice Address - Country:US
Practice Address - Phone:626-961-0876
Practice Address - Fax:909-468-4603
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6093T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060930Medicaid
CAT87313Medicare UPIN
CASD0060930Medicaid