Provider Demographics
NPI:1659422616
Name:NELSON, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BLUEBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5082
Mailing Address - Country:US
Mailing Address - Phone:478-825-8691
Mailing Address - Fax:478-825-4458
Practice Address - Street 1:601 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5082
Practice Address - Country:US
Practice Address - Phone:478-825-8691
Practice Address - Fax:478-825-4458
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00226014IMedicaid
GA00226014IMedicaid