Provider Demographics
NPI:1316998180
Name:NELSON, KYLE K (DO)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:K
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:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5984
Mailing Address - Fax:864-512-7586
Practice Address - Street 1:1520 WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-1916
Practice Address - Country:US
Practice Address - Phone:864-512-5984
Practice Address - Fax:864-512-7586
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC006479Medicaid
SCDF4920OtherRR MEDICARE
SC7043Medicare PIN
7098Medicare PIN
SCDF4920OtherRR MEDICARE
H84426Medicare UPIN