Provider Demographics
NPI:1518088921
Name:THORESEN, NELSON L (OD)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:L
Last Name:THORESEN
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 1:4495 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312
Mailing Address - Country:US
Mailing Address - Phone:423-472-5239
Mailing Address - Fax:423-472-1604
Practice Address - Street 1:4495 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312
Practice Address - Country:US
Practice Address - Phone:423-472-5239
Practice Address - Fax:423-472-1604
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT698152W00000X
GA920T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3594354Medicare ID - Type Unspecified
T61185Medicare UPIN