Provider Demographics
NPI:1447356134
Name:NELSON, BENJAMIN B (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:B
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 HEDGE APPLE DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-8986
Mailing Address - Country:US
Mailing Address - Phone:660-826-0683
Mailing Address - Fax:660-827-5470
Practice Address - Street 1:3201 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2118
Practice Address - Country:US
Practice Address - Phone:660-826-0683
Practice Address - Fax:660-827-5470
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU87738Medicare UPIN
MOP59C620Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE