Provider Demographics
NPI:1639111883
Name:NELSON, EDWARD REESE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:REESE
Last Name:NELSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 CLEARFORK MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3559
Mailing Address - Country:US
Mailing Address - Phone:817-334-1400
Mailing Address - Fax:817-334-1410
Practice Address - Street 1:1275 W. TERRELL AVE
Practice Address - Street 2:STE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2822
Practice Address - Country:US
Practice Address - Phone:817-250-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8364207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127910106Medicaid
TX127910103Medicaid
TX127910103Medicaid
TX127910106Medicaid
TX127910103Medicaid