Provider Demographics
NPI:1649386608
Name:NELSEN, MARIA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:JEAN
Last Name:NELSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6N467 E RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-6286
Mailing Address - Country:US
Mailing Address - Phone:630-762-0689
Mailing Address - Fax:847-468-9779
Practice Address - Street 1:1001 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2319
Practice Address - Country:US
Practice Address - Phone:847-468-9777
Practice Address - Fax:847-468-9779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03419OtherPROVIDER NMBER
IL03419OtherPROVIDER NMBER
IL259910Medicare ID - Type Unspecified