Provider Demographics
NPI:1679645972
Name:NAZARENO, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:NAZARENO
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 1:13650 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1152
Mailing Address - Country:US
Mailing Address - Phone:734-281-2150
Mailing Address - Fax:734-281-9142
Practice Address - Street 1:13650 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1152
Practice Address - Country:US
Practice Address - Phone:734-281-2150
Practice Address - Fax:734-281-9142
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG94557Medicare UPIN
MION32120Medicare ID - Type Unspecified