Provider Demographics
NPI:1689771487
Name:HASSELL, NELSON HOWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:HOWARD
Last Name:HASSELL
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 1:401 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4630
Mailing Address - Country:US
Mailing Address - Phone:906-774-0611
Mailing Address - Fax:906-774-2796
Practice Address - Street 1:401 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4630
Practice Address - Country:US
Practice Address - Phone:906-774-0611
Practice Address - Fax:906-774-2796
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003162152W00000X
WI2242-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38578900Medicaid
MI900B26512OtherBC/BS #
MI0M79730Medicare PIN
WI000087585Medicare PIN
MI410020033Medicare UPIN
MI900B26512OtherBC/BS #