Provider Demographics
NPI:1306843990
Name:NELSON, DARRICK P (MD)
Entity type:Individual
Prefix:
First Name:DARRICK
Middle Name:P
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DEMOSS STREET
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8367
Practice Address - Street 1:1007 N POPE ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5161
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-388-3465
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5071207Q00000X
NMMD2010-0242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156494004Medicaid
TX8AQ389OtherBCBS
NM72135361Medicaid
NMNMA100969OtherMEDICARE PTAN
NM72135361Medicaid
TX8A8414Medicare ID - Type Unspecified
TX156494004Medicaid