Provider Demographics
NPI:1376986075
Name:NELSON, MATTHEW GENE (IDC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GENE
Last Name:NELSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WINTERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-4659
Mailing Address - Country:US
Mailing Address - Phone:910-884-6996
Mailing Address - Fax:
Practice Address - Street 1:212 WINTERGREEN LN
Practice Address - Street 2:
Practice Address - City:HUBERT
Practice Address - State:NC
Practice Address - Zip Code:28539-4659
Practice Address - Country:US
Practice Address - Phone:910-884-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman