Provider Demographics
NPI:1285736355
Name:NELSON NELSON NELSON OD INC
Entity type:Organization
Organization Name:NELSON NELSON NELSON OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-623-5073
Mailing Address - Street 1:203 N NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-0590
Mailing Address - Country:US
Mailing Address - Phone:580-623-5073
Mailing Address - Fax:580-623-5020
Practice Address - Street 1:203 N NOBLE AVE
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-0590
Practice Address - Country:US
Practice Address - Phone:580-623-5073
Practice Address - Fax:580-623-5020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1011332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768490BMedicaid
OK440563785Medicare ID - Type Unspecified
OK0347170001Medicare NSC
OKCS1405Medicare PIN
OK100768490BMedicaid