Provider Demographics
NPI:1154368181
Name:BORZATTA, MARCELLO A (MD)
Entity type:Individual
Prefix:
First Name:MARCELLO
Middle Name:A
Last Name:BORZATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 S FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8457
Mailing Address - Country:US
Mailing Address - Phone:850-849-1674
Mailing Address - Fax:
Practice Address - Street 1:2260 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8457
Practice Address - Country:US
Practice Address - Phone:850-849-1642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA404792086S0129X
FLME977232086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93788OtherBCBS
FL277995100Medicaid
AE896ZMedicare PIN
FL277995100Medicaid