Provider Demographics
NPI:1689647109
Name:NELSON, MARK LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
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 1:2245 S 19TH ST
Mailing Address - Street 2:200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2945
Mailing Address - Country:US
Mailing Address - Phone:253-572-1444
Mailing Address - Fax:253-830-2528
Practice Address - Street 1:2245 S 19TH ST
Practice Address - Street 2:200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2945
Practice Address - Country:US
Practice Address - Phone:253-572-1444
Practice Address - Fax:253-830-2528
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00043072207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8895607OtherPTAN
PAH37979Medicare UPIN
PA047951Medicare ID - Type Unspecified