Provider Demographics
NPI:1013923952
Name:NELSON, DAVID WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
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 1:440 GREENFIELD AVE STE D
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3568
Mailing Address - Country:US
Mailing Address - Phone:559-582-1045
Mailing Address - Fax:559-582-2174
Practice Address - Street 1:440 GREENFIELD AVE STE D
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3500
Practice Address - Country:US
Practice Address - Phone:559-582-1045
Practice Address - Fax:559-582-2174
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG28470OtherSTATE LICENSE NUMBER
CA00G284702Medicaid
CA11D0708894OtherCLIA ID NUMBER
CA11D0708894OtherCLIA ID NUMBER
CA11D0708894OtherCLIA ID NUMBER
CA00G284702Medicaid
CA11D0708894OtherCLIA ID NUMBER