Provider Demographics
NPI:1578098166
Name:ZAMORA, MARIO PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:PHILLIP
Last Name:ZAMORA
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 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2300
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:901-522-2600
Practice Address - Street 1:6325 HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2300
Practice Address - Country:US
Practice Address - Phone:901-522-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS308902084N0400X
TN638662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200007030Medicaid
TNQ067438Medicaid