Provider Demographics
NPI:1285792093
Name:NELSON, KURT KENNETH (OD)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:KENNETH
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 N GALENA AVE
Mailing Address - Street 2:P.O. BOX 572
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1664
Mailing Address - Country:US
Mailing Address - Phone:815-284-6866
Mailing Address - Fax:815-284-2388
Practice Address - Street 1:629 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1664
Practice Address - Country:US
Practice Address - Phone:815-284-6866
Practice Address - Fax:815-284-2388
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0567270001Medicare NSC
ILT37408Medicare UPIN
IL674890Medicare ID - Type Unspecified