Provider Demographics
NPI:1649212085
Name:ALONSOZANA, EDGAR L (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:L
Last Name:ALONSOZANA
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 64075
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9882
Practice Address - Fax:410-234-2558
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD51140207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKU59ST / 603146-01OtherBC / BS OF MD
MDS185 / 0013OtherBLUECHOICE
MD100320800Medicaid
MDS797ST / S797STOtherBC / BS OF MD
S797 / 692WMedicare ID - Type Unspecified
MD100320800Medicaid