Provider Demographics
NPI:1790932432
Name:NELSON, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
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 1:4500 S LANCASTER RD # 11QC
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:214-857-2153
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD # 11QC
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine