NPIMap

Organization Active NPI

Ivan L Mazzorana Jr MD PA

  • Psychiatry Physician
  • Ft Myers, FL
National Provider Identifier
1790877488
Registry record updated Nov 15, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
IVAN L MAZZORANA JR MD PA
Practice address
12590 Whitehall Dr
Suite 3
Ft Myers, FL 33907-3620
Phone
(239) 939-9090
Fax
(239) 939-2922
NPI assigned
Sep 29, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 15, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ivan L Mazzorana Jr., MDNPI 1669480653
Title
President
Phone
(239) 939-9090

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

12590 Whitehall Dr
Suite 3
Ft Myers, FL 33907-3620

Mailing address

12590 Whitehall Dr
Suite 3
Ft Myers, FL 33907-3620
Phone (239) 939-9090

Other identifiers 2

IdentifierTypeStateIssuer
3189574OtherGHI
990014183OtherMEDICARE R.R.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040126000086 FL Part B Supplier - Clinic/Group Practice 5395647754 Receives reassigned benefits from 14 practitioners
Practice locations: Fort Myers, FL

National Provider Directory

National Provider Directory

Locations

15101 Shell Point Blvd
Fort Myers, FL 33908
Phone (239) 446-1131

12590 Whitehall Dr
Ste 3
Fort Myers, FL 33907
Phone (239) 936-9338

4755 Summerlin Rd
Ste 3
Fort Myers, FL 33919
Phone (239) 936-4333

Practitioners & affiliated clinicians

Practitioners 19

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 19

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1352937600000",
    "number": "1790877488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12590 WHITEHALL DR",
            "address_2": "SUITE 3",
            "city": "FT MYERS",
            "state": "FL",
            "postal_code": "339073620",
            "telephone_number": "239-939-9090",
            "fax_number": "239-939-2922"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12590 WHITEHALL DR",
            "address_2": "SUITE 3",
            "city": "FT MYERS",
            "state": "FL",
            "postal_code": "339073620",
            "telephone_number": "239-939-9090",
            "fax_number": "239-939-2922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVAN L MAZZORANA JR MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-29",
        "last_updated": "2012-11-15",
        "status": "A",
        "authorized_official_last_name": "MAZZORANA",
        "authorized_official_first_name": "IVAN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "239-939-9090",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GHI",
            "identifier": "3189574",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE R.R.",
            "identifier": "990014183",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ft Myers, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.