Provider Demographics
NPI:1376582908
Name:MARIANO, M. JERRY ZAPANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:M. JERRY
Middle Name:ZAPANTA
Last Name:MARIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M. JERRY
Other - Middle Name:Z
Other - Last Name:MARIANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-9603
Mailing Address - Country:US
Mailing Address - Phone:218-326-3433
Mailing Address - Fax:218-326-3435
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9603
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43720207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN184514400Medicaid
MN43720OtherSTATE LICENSE
MN184514400Medicaid
MN43720OtherSTATE LICENSE
MN180001012Medicare ID - Type UnspecifiedHIBBING LOCATION