Provider Demographics
NPI:1558496950
Name:NELSON, GREG J (MD)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:J
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:PO BOX 55637
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-0637
Mailing Address - Country:US
Mailing Address - Phone:818-785-8707
Mailing Address - Fax:818-785-1152
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE 212
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-785-8707
Practice Address - Fax:818-785-1152
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67260174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF10266Medicare UPIN
CAW15495Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID