Provider Demographics
NPI:1790877488
Name:IVAN L MAZZORANA JR MD PA
Entity Type:Organization
Organization Name:IVAN L MAZZORANA JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAZZORANA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:239-939-9090
Mailing Address - Street 1:12590 WHITEHALL DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3620
Mailing Address - Country:US
Mailing Address - Phone:239-939-9090
Mailing Address - Fax:239-939-2922
Practice Address - Street 1:12590 WHITEHALL DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3620
Practice Address - Country:US
Practice Address - Phone:239-939-9090
Practice Address - Fax:239-939-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3189574OtherGHI
990014183OtherMEDICARE R.R.
990014183OtherMEDICARE R.R.