Provider Demographics
NPI:1720058654
Name:NELSON, TIMOTHY L (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
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 1:203 N NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-0590
Mailing Address - Country:US
Mailing Address - Phone:580-623-5073
Mailing Address - Fax:580-623-5020
Practice Address - Street 1:203 N NOBLE AVE
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-0590
Practice Address - Country:US
Practice Address - Phone:580-623-5073
Practice Address - Fax:580-623-5020
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730989130001OtherBCBS PROVIDER NUMBER
OK100761510AMedicaid
OK0347170001Medicare NSC
OK410017591Medicare PIN
OKT40588Medicare UPIN