Provider Demographics
NPI:1093916116
Name:ZAHN, MARY BRANAN ENNIS (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRANAN ENNIS
Last Name:ZAHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 713
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8210
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 713
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63859207P00000X
FLME 107442207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002687800Medicaid
GA643928689AMedicaid
FL148Y4OtherBLUE CROSS
FL002687800Medicaid