Provider Demographics
NPI:1992878409
Name:NELSON, DAVID PAUL (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
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 1:427 W COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9385
Mailing Address - Country:US
Mailing Address - Phone:608-839-0980
Mailing Address - Fax:608-839-0982
Practice Address - Street 1:427 W COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9385
Practice Address - Country:US
Practice Address - Phone:608-839-0980
Practice Address - Fax:608-839-0982
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84199Medicare PIN
WIU72407Medicare UPIN