Provider Demographics
NPI:1750476925
Name:NELSON, GREGSTON R (MD)
Entity Type:Individual
Prefix:
First Name:GREGSTON
Middle Name:R
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 1:12728 AUGUSTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3754
Mailing Address - Country:US
Mailing Address - Phone:402-330-1410
Mailing Address - Fax:
Practice Address - Street 1:12728 AUGUSTA AVENUE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3754
Practice Address - Country:US
Practice Address - Phone:402-330-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00149OtherBLUE CROSS & BLUE SHIELD
IA7560003Medicaid
NE75304640000Medicaid
101523OtherUNITED HEALTHCARE
IA91530OtherWELLMARK BCBS IA
IA91530OtherWELLMARK BCBS IA
IA7560003Medicaid