1841579257 NPI number — MARIANNA ZADOV, P.A

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 1841579257 NPI number — MARIANNA ZADOV, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIANNA ZADOV, P.A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841579257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 CLINT MOORE RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33496-2660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-241-7656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5030 CHAMPION BLVD STE G4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33496-2478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-241-7656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LEIZGOLD
Authorized Official First Name:
SIMON
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
561-241-7656

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN164481 , 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: 1104903301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003945500 . 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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