Provider Demographics
NPI:1609239664
Name:NELSON, BENJAMIN SHAW
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SHAW
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 E NEWTON ST
Mailing Address - Street 2:C515
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-638-8442
Mailing Address - Fax:617-638-8409
Practice Address - Street 1:88 E NEWTON ST
Practice Address - Street 2:C515
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-8442
Practice Address - Fax:617-638-8409
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD24311208600000X
MA267551208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery