Basic Information
| Provider Information | |||||||||
| NPI: | 1609841931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEZZANOTTE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 E OAK ST STE A | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347445842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074760780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | ME99006 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | AA29228552 | 01 | SC | MEDICARE PTAN | OTHER | 000000245847 | 01 | SC | UNISON | OTHER | 055 | 01 | SC | BCBS | OTHER | 013 | 01 | SC | TRICARE | OTHER | 1774374 | 01 | SC | CIGNA | OTHER | 210718 | 01 | SC | MEDCOST | OTHER | 9975193 | 01 | SC | AETNA | OTHER | 5909955 | 05 | NC | MEDICAID | 20078496 | 01 | SC | SELECT HEALTH | OTHER | 311898 | 05 | SC | MEDICAID |