Provider Demographics
NPI:1891874913
Name:ZAMORA, MARK A (MPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:ZAMORA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:MR
Other - First Name:MARCO
Other - Middle Name:A
Other - Last Name:ZAMORA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1429 COLLEGE AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4057
Mailing Address - Country:US
Mailing Address - Phone:209-522-2673
Mailing Address - Fax:209-522-2955
Practice Address - Street 1:1429 COLLEGE AVE
Practice Address - Street 2:SUITE H
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4057
Practice Address - Country:US
Practice Address - Phone:209-522-2673
Practice Address - Fax:209-522-2955
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 25107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 25107OtherPHYSICAL THERAPY BOARD OF CALIFORNIA
CA0PT251071Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER