Provider Demographics
NPI:1063586170
Name:FORNASINI, NINO RENZO RENZO (MD)
Entity type:Individual
Prefix:MR
First Name:NINO RENZO
Middle Name:RENZO
Last Name:FORNASINI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3985 STEVE REYNOLDS BLVD
Mailing Address - Street 2:BLDG I
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3035
Mailing Address - Country:US
Mailing Address - Phone:770-622-3948
Mailing Address - Fax:770-622-4879
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD
Practice Address - Street 2:BLDG I
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3035
Practice Address - Country:US
Practice Address - Phone:770-622-3948
Practice Address - Fax:770-622-4879
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-07-19
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Provider Licenses
StateLicense IDTaxonomies
GA48628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000879755AMedicaid
G15768Medicare UPIN