Provider Demographics
NPI:1912934803
Name:NELSON, RICHARD A (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5721
Mailing Address - Street 2:ATTN: ADMINISTRATOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250
Mailing Address - Country:US
Mailing Address - Phone:803-779-2273
Mailing Address - Fax:803-799-0854
Practice Address - Street 1:2205 HARRISON ROAD
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824
Practice Address - Country:US
Practice Address - Phone:706-595-9534
Practice Address - Fax:706-595-6512
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1032152W00000X
GAOPT001682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20047638OtherSELECT HEALTH OF SC
SCD10325Medicaid
U58147Medicare UPIN