Provider Demographics
NPI:1417953654
Name:NELSON, MARK HARVEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HARVEY
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:MEDICAL CENTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-1332
Mailing Address - Fax:
Practice Address - Street 1:750 HIGHLAND OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7110
Practice Address - Country:US
Practice Address - Phone:336-659-1528
Practice Address - Fax:336-659-1980
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33109174400000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC62094OtherBCBS
NC4557306002OtherCIGNA
NC8962094Medicaid
NC698OtherPARTNERS
NC10053OtherOPTICARE
NC4557306002OtherCIGNA
NCD33067Medicare UPIN