Provider Demographics
NPI:1033160296
Name:ZZIWAMBAZZA, NATHAN ZZIWA (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ZZIWA
Last Name:ZZIWAMBAZZA
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:PO BOX 673397
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3397
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:620 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1002
Practice Address - Country:US
Practice Address - Phone:517-545-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074219207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4433870Medicaid
MI4527618Medicaid
MI4628227Medicaid
MI4478228Medicaid
MINZ074219OtherBLUE CROSS BLUE SHIELD
MI104735147Medicaid
MINZ074219OtherBLUE CROSS BLUE SHIELD
MI104735147Medicaid
MIH74886Medicare UPIN
MI4478228Medicaid