Provider Demographics
NPI:1811033590
Name:MARK C. NELSON, MD, INC
Entity Type:Organization
Organization Name:MARK C. NELSON, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-571-0606
Mailing Address - Street 1:9834 GENESEE AVENUE
Mailing Address - Street 2:SUITE 223
Mailing Address - City:LAJOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-777-7917
Mailing Address - Fax:858-703-5048
Practice Address - Street 1:9834 GENESEE AVENUE
Practice Address - Street 2:SUITE 223
Practice Address - City:LAJOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-777-7917
Practice Address - Fax:858-703-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80416207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA80416BOtherMEDICARE PROVIDER ID
CAW17893OtherMEDICARE PTAN
CAW17893OtherMEDICARE GROUP NUMBER
CAWA80416BOtherMEDICARE PROVIDER ID