Provider Demographics
NPI:1356336382
Name:NELSON, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:C/O MSO ADMINISTRATION
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-622-7593
Mailing Address - Fax:575-622-5538
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE #205
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:575-622-7593
Practice Address - Fax:575-622-5538
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029981208800000X
NMMD2013-0026208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0222357OtherL&I
WA8141012Medicaid
WA8944748OtherCV
WA0222357OtherL&I
WA8141012Medicaid