Provider Demographics
NPI:1669458766
Name:ZAMBUTO, DOMENIC A (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:A
Last Name:ZAMBUTO
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 1:3810 NORTHDALE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1871
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:888-812-8191
Practice Address - Street 1:3810 NORTHDALE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1871
Practice Address - Country:US
Practice Address - Phone:813-683-4784
Practice Address - Fax:888-812-8191
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU17912085R0204X
AZ679342085R0204X
IL036.1265762085R0204X
NY3238852085R0204X
CODR.00694212085R0204X
GA770112085R0204X
NJ25MA094616002085R0204X
FLME1584362085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP00918491OtherMEDICARE RAILROAD PIN
CTF81104Medicare UPIN
CTD400037374Medicare PIN
CTF81104Medicare UPIN
CTDR2994Medicare PIN
CT010040223CT01OtherANTHEM BC/BS
CTA2516306OtherOXFORD
CTD100037356Medicare PIN
CTP00918491Medicare PIN