Provider Demographics
NPI:1225359276
Name:NAZAIRE, JEAN P
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:P
Last Name:NAZAIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 JIMMY CARTER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2965
Mailing Address - Country:US
Mailing Address - Phone:770-248-1637
Mailing Address - Fax:
Practice Address - Street 1:5675 JIMMY CARTER BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2965
Practice Address - Country:US
Practice Address - Phone:770-248-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060225208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2047101Medicaid