1457329591 NPI number — THOMAS ZACHOS M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457329591 NPI number — THOMAS ZACHOS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZACHOS
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZACHOS
Provider Other First Name:
ATHANASIOS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1457329591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4154 BEACH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-2980
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-376-8739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1032 MAR WALT DR
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547-6661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-863-0883
Provider Business Practice Location Address Fax Number:
850-862-0188
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  ME38087 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 46160 . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4306752 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593-06486 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 593-06487 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 064335100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102322300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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