Provider Demographics
NPI:1497817878
Name:NELSON, DONALD R (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
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 1:1945 MESQUITE AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5889
Mailing Address - Country:US
Mailing Address - Phone:928-855-4128
Mailing Address - Fax:928-855-7539
Practice Address - Street 1:1945 MESQUITE AVE
Practice Address - Street 2:STE. A
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5889
Practice Address - Country:US
Practice Address - Phone:928-855-4128
Practice Address - Fax:928-855-7539
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ05491207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ219940Medicaid
AZZ64879Medicare PIN
AZD44315Medicare UPIN