Provider Demographics
NPI:1194718221
Name:NELSON, JOHN D (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 NE HIGHWAY 99W STE A
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2733
Mailing Address - Country:US
Mailing Address - Phone:503-472-4649
Mailing Address - Fax:503-434-1679
Practice Address - Street 1:821 NE HIGHWAY 99W STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2733
Practice Address - Country:US
Practice Address - Phone:503-472-4649
Practice Address - Fax:503-434-1679
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150722Medicaid
ORR0000BHWMQMedicare PIN
C93394Medicare UPIN