Healthcare Provider Details

I. General information

NPI: 1295773687
Provider Name (Legal Business Name): NELSON TAN MADRAZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GA HIGHWAY 27 E
AMERICUS GA
31709-3800
US

IV. Provider business mailing address

132 DOGWOOD HILLS RD
AMERICUS GA
31709-5304
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-8082
  • Fax: 229-924-8009
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49862
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: