Provider Demographics
NPI:1851390504
Name:NELSON, JOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-330-3688
Mailing Address - Fax:812-355-3270
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-330-3688
Practice Address - Fax:812-355-3270
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035192207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000300090OtherBLUE CROSS PROVIDER NO.
IN01035192OtherIN STATE LICENSE NUMBER
IN200059630Medicaid
IN01035192OtherIN STATE LICENSE NUMBER
INA03200Medicare UPIN