Provider Demographics
NPI:1124339460
Name:NELSON, CORY (DO)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N CENTER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7498
Mailing Address - Country:US
Mailing Address - Phone:801-753-7770
Mailing Address - Fax:801-753-7775
Practice Address - Street 1:3401 N CENTER ST STE 100
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7498
Practice Address - Country:US
Practice Address - Phone:801-753-7770
Practice Address - Fax:801-753-7775
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8591638-1204207Q00000X, 207QS0010X
MI5101018672208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice