Basic Information
Provider Information | |||||||||
NPI: | 1063494524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | JEREMIAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 S ILLINOIS AVE | ||||||||
Address2: | SUITE 103 | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504015489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414283041 | ||||||||
FaxNumber: | 6414283059 | ||||||||
Practice Location | |||||||||
Address1: | 910 N EISENHOWER AVE | ||||||||
Address2: |   | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504011525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414287799 | ||||||||
FaxNumber: | 6414285274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 05/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | ME 92825 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 208000000X | 35099088 | OH | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0205X | 35099088 | OH | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | ME0092825 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 207RE0101X | MD-45607 | IA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 489063073 | 01 | FL | HUMANA | OTHER | 297631 | 01 | FL | AMERIGROUP | OTHER | 297105 | 01 | FL | STAYWELL HEALTHY KIDS | OTHER | 7134730 | 01 | FL | AETNA UNITED | OTHER | 16865 | 01 | FL | BCBS | OTHER | 2438274001 | 01 | FL | CIGNA | OTHER |