Provider Demographics
NPI:1457354573
Name:PANZO, GREGORY J (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:PANZO
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 1:17560 HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6711
Mailing Address - Country:US
Mailing Address - Phone:352-735-2020
Mailing Address - Fax:352-735-3233
Practice Address - Street 1:17560 HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-735-2020
Practice Address - Fax:352-735-3233
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046534207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL180015935OtherRAILROAD MEDICARE
FL0415367700Medicaid
FL97872Medicare PIN
35214Medicare ID - Type Unspecified
FL0415367700Medicaid