Provider Demographics
NPI:1295766657
Name:NELSON, POLLY A (OD)
Entity type:Individual
Prefix:DR
First Name:POLLY
Middle Name:A
Last Name:NELSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:502 SOUTH US 71 HWY
Mailing Address - Street 2:STE 1
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-2041
Mailing Address - Country:US
Mailing Address - Phone:816-324-2020
Mailing Address - Fax:816-324-6407
Practice Address - Street 1:502 SOUTH US 71 HWY
Practice Address - Street 2:STE 1
Practice Address - City:SAVANNAH
Practice Address - State:MO
Practice Address - Zip Code:64485-2041
Practice Address - Country:US
Practice Address - Phone:816-324-2020
Practice Address - Fax:816-324-6407
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOTO2956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22793-015OtherBLUE CROSS BLUE SHIELD OF
MO312965007Medicaid
MO22793-015OtherBLUE CROSS BLUE SHIELD OF