Provider Demographics
NPI:1295773687
Name:MADRAZO, NELSON TAN (MD)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:TAN
Last Name:MADRAZO
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 1:132 DOGWOOD HILLS RD
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-5304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 GA HIGHWAY 27 E
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3800
Practice Address - Country:US
Practice Address - Phone:229-924-8082
Practice Address - Fax:229-924-8009
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA49862208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000905165DMedicaid
GA000905165EMedicaid