Provider Demographics
NPI:1316085996
Name:NELSON, LAWRENCE GRANT (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:GRANT
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6619 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2006
Mailing Address - Country:US
Mailing Address - Phone:329-259-9500
Mailing Address - Fax:321-574-8656
Practice Address - Street 1:6619 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2006
Practice Address - Country:US
Practice Address - Phone:321-259-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME139584207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1316085996Medicaid
FLME139584OtherSTATE MEDICAL LICENSE