Basic Information
| Provider Information | |||||||||
| NPI: | 1295773687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADRAZO | ||||||||
| FirstName: | NELSON | ||||||||
| MiddleName: | TAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 DOGWOOD HILLS RD | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317095304 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 GA HIGHWAY 27 E | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299248082 | ||||||||
| FaxNumber: | 2299248009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 49862 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000905165D | 05 | GA | MEDICAID | 000905165E | 05 | GA | MEDICAID |