Provider Demographics
NPI:1972709533
Name:MARIAN ZINNANTE MD, PA
Entity Type:Organization
Organization Name:MARIAN ZINNANTE MD, PA
Other - Org Name:AVENUE 360 HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-303-0496
Mailing Address - Street 1:120 N. MILLER RD
Mailing Address - Street 2:STE 300
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9173
Mailing Address - Country:US
Mailing Address - Phone:817-303-0496
Mailing Address - Fax:817-473-4329
Practice Address - Street 1:120 N. MILLER RD.
Practice Address - Street 2:STE. 300
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9173
Practice Address - Country:US
Practice Address - Phone:817-303-0496
Practice Address - Fax:817-473-4329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSTON AREA COMMUNITY SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-21
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6434207V00000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202850806Medicaid
TXR2940OtherLICENSE