Provider Demographics
NPI:1902820301
Name:NALDOZA, FAUSTINO M JR (MD)
Entity Type:Individual
Prefix:
First Name:FAUSTINO
Middle Name:M
Last Name:NALDOZA
Suffix:JR
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 1:1323 N A ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-4350
Mailing Address - Country:US
Mailing Address - Phone:620-326-8171
Mailing Address - Fax:620-326-2371
Practice Address - Street 1:1323 N A ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-4350
Practice Address - Country:US
Practice Address - Phone:620-326-8171
Practice Address - Fax:620-326-2371
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4-15591208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS000334OtherBC/BS PROVIDER #
KS100088410AMedicaid
KS100088410AMedicaid
KS003939Medicare ID - Type Unspecified