Basic Information
| Provider Information | |||||||||
| NPI: | 1780813592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LARS | ||||||||
| MiddleName: | SPENCER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 LPGA BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862740250 | ||||||||
| FaxNumber: | 3862740268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME123398 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | 390200000X | ME123398 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0127X | ME123398 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.