Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 031343 | NY |
NPI | 1083003990 |
---|---|
Provider Name | Dr. John D Nelson |
First Address | New York, NY 10022-1236 |
Second Address | New York, NY 10022-1236 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2015 |
Last Update Date | 15/01/2015 |