Provider Demographics
NPI:1457329591
Name:ZACHOS, ATHANASIOS (MD)
Entity Type:Individual
Prefix:
First Name:ATHANASIOS
Middle Name:
Last Name:ZACHOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:ZACHOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1032 MAR WALT DR
Practice Address - Street 2:SUITE 240
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6661
Practice Address - Country:US
Practice Address - Phone:850-863-0883
Practice Address - Fax:850-862-0188
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38087208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL593-06486OtherBCBS AL
FL4306752OtherAETNA
FL064335100Medicaid
FL46160OtherBCBS FL
AL593-06487OtherBCBS AL
FLD54972Medicare UPIN
FL46160WMedicare PIN