Provider Demographics
NPI:1427035534
Name:NELSON, LAWRENCE (DO)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8103 BURDEN RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8208
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:8103 BURDEN RD
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-8208
Practice Address - Country:US
Practice Address - Phone:815-713-2600
Practice Address - Fax:815-654-8020
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36089481207Q00000X
IL036-0894812086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4673170001OtherDMERC
ILP00470671OtherRAILROAD MEDICARE
ILK49581/203980Medicare PIN
IL769380 - L86153Medicare PIN
ILK49580/203979Medicare PIN
ILE33993Medicare UPIN