Provider Demographics
NPI:1174573422
Name:NELSON, KIRK LEE (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:LEE
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 SOUTHMOOR RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-3753
Mailing Address - Country:US
Mailing Address - Phone:804-675-6737
Mailing Address - Fax:804-675-6736
Practice Address - Street 1:1201 BROAD ROCK BLVD # 116A
Practice Address - Street 2:MCGUIRE VAMC
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-6737
Practice Address - Fax:804-675-6736
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010404532084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B08961Medicare UPIN