Provider Demographics
NPI:1972009751
Name:NELSON, DWAYNE O (MD)
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:O
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 1:1 FORD PLACE
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:2799 WEST GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine