Basic Information
| Provider Information | |||||||||
| NPI: | 1942231972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZEN | ||||||||
| FirstName: | ISMIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395013603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288631132 | ||||||||
| FaxNumber: | 2288651700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395013603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288631132 | ||||||||
| FaxNumber: | 2288651700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 15346 | MS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00018213 | 05 | MS | MEDICAID | 640478777 | 01 | MS | TRICARE CHAMPUS | OTHER | 255650247B | 01 | MS | BLUE CROSS BLUE SHIELD | OTHER |