Provider Demographics
NPI:1558357939
Name:NELSON, CARRIE (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 GUNDERSEN DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2402
Mailing Address - Country:US
Mailing Address - Phone:630-668-2416
Mailing Address - Fax:630-681-0522
Practice Address - Street 1:327 GUNDERSEN DR
Practice Address - Street 2:SUITE C
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2402
Practice Address - Country:US
Practice Address - Phone:630-668-2416
Practice Address - Fax:630-681-0522
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F25071Medicare UPIN