Basic Information
| Provider Information | |||||||||
| NPI: | 1194707513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAMORA | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5166 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039506 | ||||||||
| FaxNumber: | 6017033264 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 S ARCHUSA AVE | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393552325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017762123 | ||||||||
| FaxNumber: | 6017766006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 08282 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 730-07886 | 01 | BLUE CROSS OF AL | OTHER |