Provider Demographics
NPI:1639149891
Name:NELSON, JAY C (OD)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:C
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
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 967
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58602-0967
Mailing Address - Country:US
Mailing Address - Phone:701-225-2020
Mailing Address - Fax:701-483-5879
Practice Address - Street 1:446 3RD AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4940
Practice Address - Country:US
Practice Address - Phone:701-225-2020
Practice Address - Fax:701-483-5879
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND800547OtherBLUE CROSS VISION
ND60500Medicaid
410036368Medicare ID - Type UnspecifiedRAILROAD
ND60500Medicaid
ND0318650001Medicare NSC
U63321Medicare UPIN