Basic Information
| Provider Information | |||||||||
| NPI: | 1285676312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZANETOS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZANETOS | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25900 N HIGHWAY 99 | ||||||||
| Address2: | |||||||||
| City: | ACAMPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952209392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093399022 | ||||||||
| FaxNumber: | 2093399033 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | HOLLISTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950235602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316375711 | ||||||||
| FaxNumber: | 8316362685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 20A5351 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00AX53510 | 05 | CA | MEDICAID |