Provider Demographics
NPI:1437137429
Name:NELSON, RICHARD LOREN (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LOREN
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12817 FORD TRL S
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-8930
Mailing Address - Country:US
Mailing Address - Phone:515-961-7573
Mailing Address - Fax:515-961-7586
Practice Address - Street 1:1500 N JEFFERSON WAY
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-1465
Practice Address - Country:US
Practice Address - Phone:515-961-7573
Practice Address - Fax:515-961-7586
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01595152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
T01078Medicare UPIN
I10146Medicare ID - Type Unspecified