Provider Demographics
NPI:1407841695
Name:NELSON, RUSS TODD (LPT)
Entity Type:Individual
Prefix:
First Name:RUSS
Middle Name:TODD
Last Name:NELSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 TEXAS BLVD
Mailing Address - Street 2:STE 8
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3097
Mailing Address - Country:US
Mailing Address - Phone:903-793-1797
Mailing Address - Fax:903-793-2105
Practice Address - Street 1:4303 TEXAS BLVD
Practice Address - Street 2:STE 8
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3097
Practice Address - Country:US
Practice Address - Phone:903-793-1797
Practice Address - Fax:903-793-2105
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1090942OtherTX LICENSE
AR99451OtherAR BCBS NUMBER
TX86940TOtherBCBS ID NUMBER