Provider Demographics
NPI:1982687042
Name:NELSON, SCOTT EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDGAR
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 1:612 W DUARTE RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7602
Mailing Address - Country:US
Mailing Address - Phone:626-445-3900
Mailing Address - Fax:626-445-3985
Practice Address - Street 1:612 W DUARTE RD
Practice Address - Street 2:SUITE 404
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7602
Practice Address - Country:US
Practice Address - Phone:626-445-3900
Practice Address - Fax:626-445-3985
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91314Medicare UPIN
CAG30870Medicare ID - Type Unspecified