Provider Demographics
NPI:1609090158
Name:MARCELLO A BORZATTA MD PA
Entity Type:Organization
Organization Name:MARCELLO A BORZATTA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLO
Authorized Official - Middle Name:A
Authorized Official - Last Name:BORZATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-398-5090
Mailing Address - Street 1:2260 S FERDON BLVD
Mailing Address - Street 2:#214
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8457
Mailing Address - Country:US
Mailing Address - Phone:850-398-5090
Mailing Address - Fax:850-398-5097
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:SUITE 430
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-398-5090
Practice Address - Fax:850-398-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277995100Medicaid
93788OtherBCBS
FL277995100Medicaid
FLAE924Medicare PIN