Provider Demographics
NPI:1902202575
Name:NELON MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:NELON MEDICAL GROUP PLLC
Other - Org Name:NELON MEDICAL GROUP PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/D.O
Authorized Official - Prefix:DR
Authorized Official - First Name:BURLYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-447-1208
Mailing Address - Street 1:434 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5330
Practice Address - Country:US
Practice Address - Phone:817-447-1208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid