Basic Information
Provider Information | |||||||||
NPI: | 1306843990 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | DARRICK | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 530 DEMOSS STREET | ||||||||
Address2: |   | ||||||||
City: | LORDSBURG | ||||||||
State: | NM | ||||||||
PostalCode: | 880452618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755428384 | ||||||||
FaxNumber: | 5755428367 | ||||||||
Practice Location | |||||||||
Address1: | 1007 N POPE ST | ||||||||
Address2: |   | ||||||||
City: | SILVER CITY | ||||||||
State: | NM | ||||||||
PostalCode: | 880615161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753881511 | ||||||||
FaxNumber: | 5753883465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2005 | ||||||||
LastUpdateDate: | 09/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L5071 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD2010-0242 | NM | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 156494004 | 05 | TX |   | MEDICAID | 8AQ389 | 01 | TX | BCBS | OTHER | 72135361 | 05 | NM |   | MEDICAID | NMA100969 | 01 | NM | MEDICARE PTAN | OTHER |