Provider Demographics
NPI:1669632188
Name:MARIO NELSON MD PC
Entity Type:Organization
Organization Name:MARIO NELSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-365-2881
Mailing Address - Street 1:265 N MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-3702
Mailing Address - Country:US
Mailing Address - Phone:845-365-2881
Mailing Address - Fax:845-290-6977
Practice Address - Street 1:265 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-3702
Practice Address - Country:US
Practice Address - Phone:845-365-2881
Practice Address - Fax:845-290-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBN0226375208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA63098Medicare UPIN