Provider Demographics
NPI:1679641708
Name:ZENDEHROUH, PEDRAM (MD)
Entity Type:Individual
Prefix:
First Name:PEDRAM
Middle Name:
Last Name:ZENDEHROUH
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 1:5220 BELFORT RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:904-446-3451
Mailing Address - Fax:904-446-3013
Practice Address - Street 1:951 N WASHINGTON AVE
Practice Address - Street 2:PARRISH WOUND HEALING CENTER
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2163
Practice Address - Country:US
Practice Address - Phone:321-268-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016404208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263006OtherTRICARE
MOP00195701OtherRAILROAD MEDICARE
MO209022003Medicaid
MO923263268Medicare PIN
MOP00195701OtherRAILROAD MEDICARE