Provider Demographics
NPI:1598718314
Name:NELSON, DALLAS LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:LEE
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 1:76 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2323
Mailing Address - Country:US
Mailing Address - Phone:585-242-9399
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:BOX 58
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2733
Practice Address - Country:US
Practice Address - Phone:585-341-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223415207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010223415OtherBLUE CHOICE
NY1391568JOtherPREFERRED CARE
NYP020223415OtherBLUE SHIELD
NY025343361Medicaid
NYI35570Medicare UPIN
NY025343361Medicaid