Provider Demographics
NPI:1326215617
Name:NELSON, BRENT (DO)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
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 1:5040 N 15TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3328
Mailing Address - Country:US
Mailing Address - Phone:602-248-0123
Mailing Address - Fax:602-248-8506
Practice Address - Street 1:5040 N 15TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3328
Practice Address - Country:US
Practice Address - Phone:602-248-0123
Practice Address - Fax:602-248-8506
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ425247Medicaid