Basic Information
| Provider Information | |||||||||
| NPI: | 1467471235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARZANO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2338 IMMOKALEE RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341101445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394304674 | ||||||||
| FaxNumber: | 2394300055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 TAMIAMI TRL N | ||||||||
| Address2: | STE 101 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394304674 | ||||||||
| FaxNumber: | 2396596530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | ME81325 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 260090100 | 05 | FL | MEDICAID | 51707 | 01 | FL | BCBS PROVIDER | OTHER |