Provider Demographics
NPI:1811185747
Name:NELSON-NAM A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:NELSON-NAM A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-785-8707
Mailing Address - Street 1:PO BOX 55637
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-0637
Mailing Address - Country:US
Mailing Address - Phone:818-785-8707
Mailing Address - Fax:818-785-1152
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE 212
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-785-8707
Practice Address - Fax:818-785-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15495Medicare PIN