Provider Demographics
NPI:1699756627
Name:NAZARIO, RUBEN J (MD)
Entity type:Individual
Prefix:
First Name:RUBEN
Middle Name:J
Last Name:NAZARIO
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 1:12092 ANTLER CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6167
Mailing Address - Country:US
Mailing Address - Phone:703-989-1925
Mailing Address - Fax:
Practice Address - Street 1:200 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5726
Practice Address - Country:US
Practice Address - Phone:410-848-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059012208000000X
MDD0072015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006695E14Medicare ID - Type Unspecified
MD006695E14Medicare ID - Type Unspecified
H32646Medicare UPIN