Basic Information
| Provider Information | |||||||||
| NPI: | 1649269614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493646000 | ||||||||
| FaxNumber: | 9493641204 | ||||||||
| Practice Location | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493646000 | ||||||||
| FaxNumber: | 9493641204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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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 | 207RA0201X | G046205 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207R00000X | G046205 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G462050 | 05 | CA | MEDICAID |