Provider Demographics
NPI:1962487462
Name:NELSON, ROSCOE S (MD)
Entity type:Individual
Prefix:DR
First Name:ROSCOE
Middle Name:S
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 1:2965 W 3500 S DEPT CODE902
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:1159 E 200 N STE 300
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2037
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27180208800000X
UT13713178-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467870Medicaid
AZZ184433Medicare PIN
AZG87196Medicare UPIN
AZ340018596Medicare ID - Type UnspecifiedRAILROAD MEDICARE
AZ65588Medicare ID - Type Unspecified
AZ467870002Medicaid