Provider Demographics
NPI:1891736146
Name:NELSON, STANLEY J (OD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66508-1841
Mailing Address - Country:US
Mailing Address - Phone:785-562-2631
Mailing Address - Fax:785-562-4006
Practice Address - Street 1:715 BROADWAY
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1841
Practice Address - Country:US
Practice Address - Phone:785-562-2631
Practice Address - Fax:785-562-4006
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1124-3152W00000X, 152WC0802X, 152WL0500X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100250616-00Medicaid
KS0000005204OtherBLUE CROSS & BLUE SHIELD
NE100250616-00Medicaid
KS0414580002Medicare NSC
KST43697Medicare UPIN