Basic Information
| Provider Information | |||||||||
| NPI: | 1750536520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | VERE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11781 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5717775157 | ||||||||
| FaxNumber: | 7038902650 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD COURT RD | ||||||||
| Address2: | |||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211335103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105212200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 66537 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | OS11380 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | H74967 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 60 264743 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | A-1484-08 | NM | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 20A10561 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.