MEDICARE: PROACTIVE MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U5083	OTHER	TX	TEXAS MEDICAL LICENSE

General Provider Information

NPI Number	:	1225765241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	5353 N FEDERAL HWY STE 400
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-3244
Country	:	US
Telephone Number	:	954-938-2843
Fax Number	:	954-200-6689

Provider Business Practice Location Address
First Line	:	5353 N FEDERAL HWY STE 400
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-3244
Country	:	US
Telephone Number	:	954-938-2843
Fax Number	:	954-200-6689

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICARDO ALEXANDER ZAMBRANO
Credential	:
Telephone Number	:	954-938-2843

Provider Enumeration Date	:	08/02/2022
Last Update Date	:	01/01/2024

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