Provider Demographics
NPI:1821161019
Name:NELSON, PAUL DANIEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DANIEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14612 PEBBLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491
Mailing Address - Country:US
Mailing Address - Phone:708-267-7888
Mailing Address - Fax:
Practice Address - Street 1:3800 HIGHLAND AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1559
Practice Address - Country:US
Practice Address - Phone:630-810-9966
Practice Address - Fax:630-810-9596
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77815Medicare UPIN
936480Medicare ID - Type Unspecified