Basic Information
| Provider Information | |||||||||
| NPI: | 1306025614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOUIS D ZEGARELLI D O P A | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KIEST PARK MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2225 VATICAN LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752244719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143333393 | ||||||||
| FaxNumber: | 2143330809 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 VATICAN LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752244719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143333393 | ||||||||
| FaxNumber: | 2143330809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZEGARELLI | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | DALE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2143333393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 146654201 | 05 | TX | MEDICAID |