Provider Demographics
NPI:1235176637
Name:MADRID, RAMON ADOLFO (MD)
Entity Type:Individual
Prefix:
First Name:RAMON
Middle Name:ADOLFO
Last Name:MADRID
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 1:2040 MONROE ST
Mailing Address - Street 2:SUITE #209
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2921
Mailing Address - Country:US
Mailing Address - Phone:313-359-3800
Mailing Address - Fax:313-277-4100
Practice Address - Street 1:2040 MONROE ST
Practice Address - Street 2:SUITE #209
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2921
Practice Address - Country:US
Practice Address - Phone:313-359-3800
Practice Address - Fax:313-277-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028439208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H219440OtherBC/BS
MI0N58980018Medicare ID - Type Unspecified
MIA77268Medicare UPIN