Provider Demographics
NPI:1457610784
Name:NELSON, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LINCOLN PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6410
Mailing Address - Country:US
Mailing Address - Phone:937-531-5020
Mailing Address - Fax:937-298-4385
Practice Address - Street 1:500 LINCOLN PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6410
Practice Address - Country:US
Practice Address - Phone:937-531-5020
Practice Address - Fax:937-298-4385
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131380207R00000X
390200000X
NH17072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226758Medicaid