Provider Demographics
NPI:1740239045
Name:NELSON, WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
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:PO BOX 7009
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-7009
Mailing Address - Country:US
Mailing Address - Phone:708-245-8900
Mailing Address - Fax:708-245-5604
Practice Address - Street 1:5101 WILLOW SPRINGS RD
Practice Address - Street 2:2ND FLR
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2600
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:708-245-5604
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36036866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL545300OtherGROUP MEDICARE PTAN
IL036036866Medicaid
IL545300OtherGROUP MEDICARE PTAN