Provider Demographics
NPI:1285749101
Name:NELSON, DEAN ALLAN (DO)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ALLAN
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 1:267 N CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5500
Mailing Address - Country:US
Mailing Address - Phone:208-934-4446
Mailing Address - Fax:208-934-4442
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4446
Practice Address - Fax:208-934-4442
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10491207P00000X, 207Q00000X
ID00352207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000096575OtherBLUE CROSS BS
ID807560000Medicaid
MT0069207Medicaid
G54184Medicare UPIN
ID1300053Medicare Oscar/Certification
000071652Medicare ID - Type Unspecified