Organization
IVAN L MAZZORANA JR MD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
IVAN L MAZZORANA JR. MD (PRESIDENT)
(239) 939-9090
Entity
Organization
Contact information
Practice address
12590 WHITEHALL DR, SUITE 3, FT MYERS, FL 33907-3620
(239) 939-9090
(239) 939-2922
Mailing address
12590 WHITEHALL DR, SUITE 3, FT MYERS, FL 33907-3620
(239) 939-9090
(239) 939-2922
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3189574
GHI
—
01
—
990014183
MEDICARE R.R.
—
Enumeration date
09/29/2006
Last updated
11/15/2012
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