Provider Demographics
NPI:1306509898
Name:NELSON, MICHAEL A (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
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 1:15900 W 127TH ST STE 221B
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-2914
Mailing Address - Country:US
Mailing Address - Phone:312-888-9999
Mailing Address - Fax:630-863-7854
Practice Address - Street 1:15900 W 127TH ST STE 221B
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-2914
Practice Address - Country:US
Practice Address - Phone:312-888-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist