Provider Demographics
NPI:1417931676
Name:NELSON, HENRY N (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:N
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 1:200 E SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3142
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-951-3124
Practice Address - Street 1:1130 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1946
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-951-3124
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36295208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020009895OtherRR MEDICARE
FL039788100Medicaid
FL020009895OtherRR MEDICARE
FL05417ZMedicare PIN