Individual
DR. EVAN NELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1775 DEMPSTER ST, PARK RIDGE, IL 60068-1143
(123) 456-7890
Mailing address
1775 DEMPSTER ST, PARK RIDGE, IL 60068-1143
(123) 456-7890
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036128613
IL
207RC0000X
Cardiovascular Disease Physician
Primary
036128613
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/16/2008
Last updated
07/23/2012
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