Provider Demographics
NPI:1295720936
Name:NELSON, JEFFREY DONALD (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DONALD
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:PO BOX 4446
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-0446
Mailing Address - Country:US
Mailing Address - Phone:510-642-7955
Mailing Address - Fax:510-643-6999
Practice Address - Street 1:2222 BANCROFT EXT
Practice Address - Street 2:UNIVERSITY HEALTH SERVICE- CLINICAL SERVICES
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4303
Practice Address - Country:US
Practice Address - Phone:510-643-7110
Practice Address - Fax:510-643-9790
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72339207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG72339OtherCALIF. MEDICAL LISCENCE
CAG65934Medicare UPIN
CA00G723390Medicare ID - Type UnspecifiedMEDICARE