Provider Demographics
NPI:1649269614
Name:NELSON, BRUCE LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LESLIE
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 315
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-364-6000
Mailing Address - Fax:949-364-1204
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 315
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-6000
Practice Address - Fax:949-364-1204
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG046205207RA0201X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G462050Medicaid
CAE04627Medicare UPIN
CAWG46205AMedicare PIN