Provider Demographics
NPI:1730465121
Name:PIZZARO, IDA THOMPSON (CST/CSFA)
Entity Type:Individual
Prefix:MISS
First Name:IDA
Middle Name:THOMPSON
Last Name:PIZZARO
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-3657
Mailing Address - Country:US
Mailing Address - Phone:229-263-4827
Mailing Address - Fax:
Practice Address - Street 1:52 BAKER ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-3657
Practice Address - Country:US
Practice Address - Phone:229-263-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO129250246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant