Provider Demographics
NPI:1093868655
Name:NAZARIAN, EDWYNE D (MD)
Entity type:Individual
Prefix:DR
First Name:EDWYNE
Middle Name:D
Last Name:NAZARIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2154 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-456-9500
Mailing Address - Fax:415-842-7691
Practice Address - Street 1:1036 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1427
Practice Address - Country:US
Practice Address - Phone:415-456-9500
Practice Address - Fax:415-456-6604
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA389822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A389820Medicare ID - Type Unspecified
CAA28785Medicare UPIN