Provider Demographics
NPI:1699824045
Name:NELSON, KEVIN REED (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:REED
Last Name:NELSON
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 1:228 BELLOWS AVE
Mailing Address - Street 2:P.O. BOX 2158
Mailing Address - City:FRANKFORT
Mailing Address - State:MI
Mailing Address - Zip Code:49635-2158
Mailing Address - Country:US
Mailing Address - Phone:231-352-9141
Mailing Address - Fax:231-352-9739
Practice Address - Street 1:228 BELLOWS AVENUE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:MI
Practice Address - Zip Code:49635-2158
Practice Address - Country:US
Practice Address - Phone:231-352-9141
Practice Address - Fax:231-352-9739
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3200186Medicaid
MI900A065010OtherBCBS
MI900A065010OtherBCBS
112816000Medicare ID - Type Unspecified
MI3200186Medicaid
MI1128160001Medicare NSC