Provider Demographics
NPI:1063492676
Name:ZEGARRA, TED EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:EDWARD
Last Name:ZEGARRA
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 1:1739 E BEVERLY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-692-3456
Mailing Address - Fax:928-692-7071
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-692-3456
Practice Address - Fax:928-692-7071
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ871203Medicaid
AZ29946OtherMEDICAL LICENSE
AZBZ0121880OtherDEA
AZB27815Medicare UPIN
AZ29946OtherMEDICAL LICENSE