Provider Demographics
NPI:1255344164
Name:NELSON, RANDY NORMAN (DO)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:NORMAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29117 LAKEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-9354
Mailing Address - Country:US
Mailing Address - Phone:320-243-5605
Mailing Address - Fax:
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1445
Practice Address - Country:US
Practice Address - Phone:320-243-3767
Practice Address - Fax:320-243-3174
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG15528Medicare UPIN