Provider Demographics
NPI:1699948695
Name:ZONDAG, BETTY (OD)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:ZONDAG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8960 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3403
Mailing Address - Country:US
Mailing Address - Phone:772-337-6376
Mailing Address - Fax:772-337-3977
Practice Address - Street 1:8960 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3403
Practice Address - Country:US
Practice Address - Phone:772-337-6376
Practice Address - Fax:772-337-3977
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U16452Medicare UPIN