Basic Information
Provider Information | |||||||||
NPI: | 1790748192 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | CARLETON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 69 | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105320069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9144938375 | ||||||||
FaxNumber: | 9143471832 | ||||||||
Practice Location | |||||||||
Address1: | 19 BRADHURST AVE | ||||||||
Address2: | SUITE 2100 | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9144938375 | ||||||||
FaxNumber: | 9143471832 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 207RH0000X | 128109 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
ID | Type | State | Issuer | Description | 00420677 | 05 | NY |   | MEDICAID |