Provider Demographics
NPI:1639419385
Name:NELSON, JEROM (OD)
Entity Type:Individual
Prefix:DR
First Name:JEROM
Middle Name:
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 1:1124 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6414
Mailing Address - Country:US
Mailing Address - Phone:575-434-1200
Mailing Address - Fax:575-437-3947
Practice Address - Street 1:1124 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6414
Practice Address - Country:US
Practice Address - Phone:575-434-1200
Practice Address - Fax:575-437-3947
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDODP-100286152W00000X
NM673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program