Provider Demographics
NPI:1922087071
Name:GWINN, NELSON III (MD)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:
Last Name:GWINN
Suffix:III
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 1:1150 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3022
Mailing Address - Country:US
Mailing Address - Phone:334-712-1929
Mailing Address - Fax:334-712-2799
Practice Address - Street 1:1150 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-712-1929
Practice Address - Fax:334-712-2799
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15644207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000088713Medicaid
AL009941307Medicaid
AL000055299Medicaid
AL051088713OtherBLUE CROSS
AL051055299OtherBLUE CROSS
AL051538730OtherBLUE CROSS
FL61699OtherBLUE CROSS
AL529301110Medicaid
FL258388700Medicaid
631087996OtherTAX ID#
GA00459225BMedicaid
AL051540195OtherBLUE CROSS
FL054182600Medicaid
AL000088713Medicare ID - Type Unspecified
AL000038730Medicare PIN
AL000055299Medicare PIN
631087996OtherTAX ID#
AL051088713OtherBLUE CROSS
AL000088713Medicaid
AL529301110Medicaid