Provider Demographics
NPI:1902838063
Name:NELSON, LIONEL MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:MARSHALL
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 1:6060 HELLYER AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1046
Mailing Address - Country:US
Mailing Address - Phone:408-227-6300
Mailing Address - Fax:408-227-6314
Practice Address - Street 1:2505 SAMARITAN DR #510
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124
Practice Address - Country:US
Practice Address - Phone:408-358-6163
Practice Address - Fax:408-358-2302
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19842207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G198420Medicaid
CA00G198420Medicaid
00G198420Medicare ID - Type Unspecified