Provider Demographics
NPI:1508085499
Name:NELSON R. MALDONADOM.D.,INC.
Entity Type:Organization
Organization Name:NELSON R. MALDONADOM.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-477-0931
Mailing Address - Street 1:PO BOX 2618
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-2618
Mailing Address - Country:US
Mailing Address - Phone:530-477-0931
Mailing Address - Fax:530-477-0934
Practice Address - Street 1:150 CATHERINE LN
Practice Address - Street 2:SUITE G
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5719
Practice Address - Country:US
Practice Address - Phone:530-477-0931
Practice Address - Fax:530-477-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208600000X208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53915OtherLICENCE
CA00G539150Medicaid
CAZZZ01292ZMedicare ID - Type Unspecified
CAG53915OtherLICENCE