Provider Demographics
NPI:1215910120
Name:NELSON, RHETT BARRY (MD)
Entity type:Individual
Prefix:
First Name:RHETT
Middle Name:BARRY
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-697-5570
Mailing Address - Fax:951-697-5596
Practice Address - Street 1:6405 DAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0901
Practice Address - Country:US
Practice Address - Phone:951-697-5570
Practice Address - Fax:951-697-5596
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19117207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730180415OtherGROUP NPI
AZ1780782557OtherSITE NPI
ZZZ31887ZOtherGROUP SITE NUMBER
CAZZZ92058ZOtherOFFICE SITE #
00G191170Medicare ID - Type Unspecified