Provider Demographics
NPI:1417242520
Name:MIRA ZELIN, DO, LLC
Entity Type:Organization
Organization Name:MIRA ZELIN, DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-530-7035
Mailing Address - Street 1:PO BOX 12038
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-2038
Mailing Address - Country:US
Mailing Address - Phone:479-601-2314
Mailing Address - Fax:479-246-9005
Practice Address - Street 1:12440 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2628
Practice Address - Country:US
Practice Address - Phone:479-601-2314
Practice Address - Fax:479-246-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11859208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty