Provider Demographics
NPI:1063769412
Name:NANGI SHORES MEDICAL GROUP
Entity type:Organization
Organization Name:NANGI SHORES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALPHONSE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DUFRENY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-756-9392
Mailing Address - Street 1:9999 NE 2ND AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2345
Mailing Address - Country:US
Mailing Address - Phone:305-384-8789
Mailing Address - Fax:786-953-4169
Practice Address - Street 1:9999 NE 2ND AVE STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2345
Practice Address - Country:US
Practice Address - Phone:305-384-8789
Practice Address - Fax:786-953-4169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-04
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85072172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1356311822OtherNPI
FL267153100Medicaid
FLE86950Medicare UPIN