Provider Demographics
NPI:1417928359
Name:NELSON, JOHN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:DANIEL
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:MAIL STOP 41102E
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7500
Practice Address - Fax:651-254-7557
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23769207W00000X
WI23769207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A95260Medicare UPIN