Provider Demographics
NPI: | 1760542054 |
---|---|
Name: | ZENDEJAS RUIZ, IVAN RODRIGO (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | IVAN |
Middle Name: | RODRIGO |
Last Name: | ZENDEJAS RUIZ |
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: | 5171 S COTTONWOOD ST |
Mailing Address - Street 2: | STE 650 |
Mailing Address - City: | MURRAY |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84107-5716 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-265-0606 |
Mailing Address - Fax: | 352-265-0678 |
Practice Address - Street 1: | 5171 S COTTONWOOD ST |
Practice Address - Street 2: | STE 650 |
Practice Address - City: | MURRAY |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84107-5716 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-265-0606 |
Practice Address - Fax: | 352-265-0678 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-09 |
Last Update Date: | 2016-06-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | 10757 | 204F00000X |
FL | ME108537 | 208600000X |
UT | 9580790-1205 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | |
No | 204F00000X | Allopathic & Osteopathic Physicians | Transplant Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | EE869Z | Medicare PIN | |
FL | 002878400 | Medicaid |