Provider Demographics
NPI:1285696278
Name:NELSON, SCOTT R (DO, FACEP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24361 EL TORO RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-2755
Mailing Address - Country:US
Mailing Address - Phone:949-916-6321
Mailing Address - Fax:949-916-6340
Practice Address - Street 1:24361 EL TORO RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-2755
Practice Address - Country:US
Practice Address - Phone:949-916-6321
Practice Address - Fax:949-916-6340
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3643207P00000X, 207PE0005X, 2083P0500X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136522311Medicaid
TX136522311Medicaid
TXD97586Medicare UPIN