Provider Demographics
NPI:1831400746
Name:NELSON, OLIVIA (MD)
Entity type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAST PENN SQUARE
Mailing Address - Street 2:THE WANAMAKER BLDG., 9TH FL., N
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9320
Mailing Address - Fax:267-425-9331
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:SUITE 9329
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MABB5204071-ON4390200000X
MA390200000X
PAMD460796207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033208840001Medicaid