Provider Demographics
NPI:1104813237
Name:NELSON, GLENN E (DPM)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 N ROSEMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2139
Mailing Address - Country:US
Mailing Address - Phone:520-886-1176
Mailing Address - Fax:520-290-8894
Practice Address - Street 1:2308 N ROSEMONT BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2139
Practice Address - Country:US
Practice Address - Phone:520-886-1176
Practice Address - Fax:520-290-8894
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0310213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00198920OtherRAIL ROAD MEDICARE
AZ701004Medicaid
AZ5335660001Medicare NSC
AZZ100279Medicare PIN