Provider Demographics
NPI:1285729921
Name:CAZZOLA, EDWARD BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:BENJAMIN
Last Name:CAZZOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 LANG AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4495
Mailing Address - Country:US
Mailing Address - Phone:505-828-3787
Mailing Address - Fax:
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:505-857-8479
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM8125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C97612Medicare UPIN
NMNM300180Medicare UPIN