Provider Demographics
NPI:1356362008
Name:NELSON, STEPHEN LANIER (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LANIER
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 1:749 GOLF VIEW DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9654
Mailing Address - Country:US
Mailing Address - Phone:541-282-6580
Mailing Address - Fax:541-326-0361
Practice Address - Street 1:749 GOLF VIEW DR UNIT A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9654
Practice Address - Country:US
Practice Address - Phone:541-282-6580
Practice Address - Fax:541-326-0361
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR066043Medicaid
OR066043Medicaid
ORR134970Medicare PIN